Clinical Pearl with Links and Articles

jamapediatrics_urashima_2019_oi_190069.pdf

The evidence suggests that sensitization to cow’s milk and food allergy, including cow's milk allergy and anaphylaxis, are primarily preventable by avoiding cow's milk formula supplementation for at least the first 3 days of life.

bmj.i5044.full.pdf

Antenatal steroids at ≥34 weeks’ gestation reduce neonatal respiratory morbidity. A single course of

corticosteroids can be considered for women at risk of imminent late premature delivery 34.0-36.6 weeks’ gestation, as well as for women undergoing planned cesarean delivery at ≥37 weeks’ gestation. 

RCT of ibuprofen plus muscle relaxant for acute LBP.pdf

POEM- muscle relaxant for acute LBP.pdf  

Adding a muscle relaxant to treatment with ibuprofen does not improve functional outcomes or pain, or lessen the number of people reporting moderate to severe back pain one week after starting treatment. (Level of Evidence = 1b) 

Misoprostol alone for first tri med ab.pdf

Misoprostol alone is effective and safe and is a reasonable option for women seeking abortion in the first trimester. Research is indicated to further refine the regimen and to establish efficacy in the late first trimester.

Using shame resilience to decrease depressive symptoms in an

adult intensive outpatient population

Shame Resilience to decrease depressive symptoms.pdf

Adding shame resilience therapy to traditional psychotherapy may be useful to improve patient adherence and alliance but further evidence is needed.

Cochrane for Clinicians:  Salt intake in CKD- AFP.pdf

Cochrane Article: https://pubmed.ncbi.nlm.nih.gov/25691262/

Reducing salt intake lowers blood pressure and reduces proteinuria in patients with CKD, but there is no evidence to determine whether lowering salt consumption leads to clinically significant reductions in end-stage renal disease, cardiovascular events, or all-cause mortality. 

Cervical cancer screening update

Honey for symptomatic URI 

Treatment of myofascial pain with exercise or trigger point injections

Cervical Cancer Screening Update.pdf

These new screening recommendations differ in 4 important respects compared with the 2012

recommendations: 1) The preferred screening strategy is primary HPV testing every 5 years, with cotesting and cytology alone acceptable where access to US Food and Drug Administration-approved primary HPV testing is not yet available; 2) the recommended age to start screening is 25 years rather than 21 years; 3) primary HPV testing, as well as cotesting or cytology alone when primary testing is not available, is recommended starting at age 25 years rather than age 30 years; and 4) the guideline is transitional, ie, options for screening with cotesting or cytology alone are provided but should be phased out once full access to primary HPV testing for cervical cancer screening is available without barriers.

Honey for symptom relief in URI.pdf

Honey was superior to usual care for the improvement of symptoms of upper respiratory tract infections. It provides a widely available and cheap alternative to antibiotics.  Honey could help efforts to slow the spread of antimicrobial resistance, but further high quality, placebo controlled trials are needed.

Exercise reduces myofascial pain- SR.pdf

Effect of dry needling and MET on trigger points.pdf

Dry needling for low back pain.pdf

Evidence for dry needling.pdf 

These data, combined with others, suggest gabapentin might be most efficacious in people with AUD and a history of alcohol withdrawal symptoms. Future studies should evaluate sleep changes and mood during early recovery as mediators of gabapentin efficacy.

Modern bariatric procedures have strong evidence of efficacy and safety. All patients with severe obesity—and especially those with type 2 diabetes—should be engaged in a shared decision-making conversation about the risks and benefits of surgery compared with continuing usual medical and lifestyle treatment, and the decision about surgery should be driven primarily by informed patient preferences.

approach to thyroid disorders in elders.pdf, Approach to Thyroid Dysfunction in Elders.pptx, CAT_RK SEH EBM 10.19.20.doc

Levothyroxine provided no apparent benefits in older persons with subclinical hypothyroidism.

Thyroid Hormone Therapy for Older Adults with Subclinical Hypothyroidism NEJM.pdf

ATA 2014 hypothyroid guidelines.pdf

2016 hyperthyroid guidelines.pdf

Statistical power explanation @0:38: https://www.youtube.com/watch?v=Rsc5znwR5FA&ab_channel=StatQuestwithJoshStarmer

-- Power analysis @11:50: https://www.youtube.com/watch?v=VX_M3tIyiYk&ab_channel=StatQuestwithJoshStarmer

Nonfasting LDL-C has prognostic value similar to that of fasting LDL-C. National and international agencies should consider reevaluating the recommendation that patients fast before obtaining a lipid panel. 

https://www.ahajournals.org/doi/10.1161/CIRCULATIONAHA.114.010001?url_ver=Z39.88-2003&rfr_id=ori%3Arid%3Acrossref.org&rfr_dat=cr_pub++0pubmed&

Fasting-Evoked En Route Hypoglycemia in Diabetes.pdf

Not So Fast _ AACC.org.pdf

To-Be or Not-To-Be Fasting.pptx 

Metformin compared with placebo or diet and exercise reduced or delayed the risk of T2DM in people at increased risk for the development of T2DM (moderate-quality evidence). However, metformin compared to intensive diet and exercise did not reduce or delay the risk of T2DM (moderate-quality evidence). 

Metformin for prevention or delay of type 2 DM- Cochrane.pdf 

Routine ingestion by hypertensive patients of ≥1 prescribed BP-lowering medications at bedtime, as opposed to upon waking, results in improved ABP control (significantly enhanced decrease in asleep BP and increased sleep-time relative BP decline, i.e. BP dipping) and, most importantly, markedly diminished occurrence of major CVD events. 

https://academic.oup.com/eurheartj/advance-article/doi/10.1093/eurheartj/ehz754/5602478

Link to the AFP article (link for action plan here): https://www.aafp.org/afp/2020/0515/p590.html 

Link for patient's resources: https://familydoctor.org/condition/eczema-and-atopic-dermatitis

Link for tool to determine severity: http://scorad.corti.li​

OLA_atopicdermatitis.pptx , AtopicdermatitisOLAandPICS.pptx 

There is moderate‐certainty evidence that ECs with nicotine increase quit rates compared to ECs without nicotine and compared to NRT. Evidence comparing nicotine EC with usual care/no treatment also suggests benefit, but is less certain. More studies are needed to confirm the degree of effect, particularly when using modern EC products.

https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD010216.pub4/full 

https://www.evidencealerts.com/Home/Article/95547 

In patients aged 75 years and older, lipid lowering was as effective in reducing cardiovascular events as it was in patients younger than 75 years. These results should strengthen guideline recommendations for the use of lipid-lowering therapies, including non-statin treatment, in older patients.

Use of Vitamin C with Iron Supplementation

in Iron Deficiency Anemia

Among patients with IDA, oral iron supplements alone were equivalent to oral iron supplements plus vitamin C in improving hemoglobin recovery and iron absorption. These findings suggest that on-demand vitamin C supplements are not essential to take along with oral iron supplements for patients with IDA.

IDA Vitamin C Supplements.pdf  

C-Reactive Protein Testing to Guide Antibiotic Prescribing for COPD Exacerbations.pdf

CRP-guided prescribing of antibiotics for exacerbations of COPD in primary care clinics resulted in a lower percentage of patients who reported antibiotic use and who received antibiotic prescriptions from clinicians, with no evidence of harm.

Treatment of COPD exacerbation.pdf

Antibiotics and systemic corticosteroids reduce treatment failure in adults with mild to severe exacerbation of COPD.

Bupropion and Naltrexone in Methamphetamine Use Disorder.pdf

Among adults with methamphetamine use disorder, the response over a period of 12 weeks among participants who received extended-release injectable naltrexone plus oral extended-release bupropion was low but was higher than that among participants who received placebo.

Colchicine for coronary disease - RCT.pdf

In a randomized trial involving patients with chronic coronary disease, the risk of cardiovascular events was significantly lower among those who received 0.5 mg of colchicine once daily than among those who received placebo. 

Levonorgestrel v Copper.pdf

The levonorgestrel IUD was noninferior to the copper IUD for emergency contraception.

Outpatient_Foley_Catheter_for_Induction_of_Labor.21.pdf

In nulliparous patients undergoing elective labor induction at term, outpatient cervical ripening with a transcervical Foley catheter reduced the time from admission to delivery.

Association between antihypertensive treatment and adverse events.pdf

This meta-analysis found no evidence to suggest that antihypertensive treatment is associated with falls but found evidence of an association with mild (hyperkalaemia, hypotension) and severe adverse events (acute kidney injury, syncope). These data could be used to inform shared decision making between doctors and patients about initiation and continuation of antihypertensive treatment, especially in patients at high risk of harm because of previous adverse events or poor renal function.

2017 ACC-AHA etc HTN Guideline.pdf 

Despite more diagnoses of gestational diabetes with the one-step approach (2 hour GTT) than with the two-step approach (1 hour GTT and then, if abnormal, 3 hour GTT) , there were no significant between-group differences in the risks of the primary outcomes relating to perinatal and maternal complications.

In this trial, Kundalini yoga was efficacious for GAD, but the results support CBT remaining first-line treatment.

Up to 2 months after symptom onset, two thirds of adults with noncritical COVID-19 had complaints, mainly anosmia/ageusia, dyspnea or asthenia. A prolonged medical follow-up of patients with COVID-19 seems essential, whatever the initial clinical presentation.  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7534895/

Guideline for managing the long term effects of COVID-19:  https://www.nice.org.uk/guidance/ng188

Syphilis Cases Averted.pdf

Missed opportunities for prevention of congenital syphilis.pdf  

A policy of labour induction compared with expectant management is associated with fewer deaths of babies and probably fewer caesarean sections; with probably little or no difference in assisted vaginal births. The best timing of when to offer induction of labour to women at or beyond 37 weeks' gestation warrants further investigation, as does further exploration of risk profiles of women and their values and preferences. 

 Induction of labor at or beyong 37 weeks -Cochrane review.pdf

SEHC presentation -Apr2021- Induction of labor.ppt

The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for vitamin D deficiency in asymptomatic adults. (I statement) 

Vitamin D screening - USPSTF.pdf

Among children with mild gastroenteritis and minimal dehydration, initial oral hydration with dilute apple juice followed by their preferred fluids, compared with electrolyte maintenance solution, resulted in fewer treatment failures. In many high-income countries, the use of dilute apple juice and preferred fluids as desired may be an appropriate alternative to electrolyte maintenance fluids in children with mild gastroenteritis and minimal dehydration.  Dilute apple juice vs. ORT for AGE.pdf

Ondansetron is the only intervention that revealed an effect on the cessation of vomiting, on preventing hospitalizations, and in reducing the need for intravenous rehydration. Ondansetron was also considered a safe intervention.  https://pediatrics.aappublications.org/content/pediatrics/145/4/e20193260.full.pdf

AFP Article: https://www.aafp.org/afp/2019/0201/p159.html 

In children with drug-resistant epilepsy, a ketogenic diet decreases the risk of seizures by 50% after three to four months (absolute risk reduction [ARR] = 37.5%; 95% CI, 19.4% to 67.6%; number needed to treat [NNT] = 3; 95% CI, 1 to 5). (Strength of Recommendation [SOR]: B, based on inconsistent or limited-quality patient-oriented evidence.)  

Ketogenic Diets for Drug-Resistant Epilepsy - Cochrane for Clinicians - American Family Physicia.pdf

Among patients with diabetes without evidence of cardiovascular disease, there was no significant difference in the risk of serious vascular events between those who were assigned to receive n−3 fatty acid supplementation and those who were assigned to receive placebo. nejmoa1804989.pdf

Supplementation with n−3 fatty acids did not result in a lower incidence of major cardiovascular events or cancer than placebo. nejmoa1811403.pdf

Among adults with obesity, metabolic–bariatric surgery is associated with substantially lower all-cause mortality rates and longer life expectancy than usual obesity management. Survival benefits are much more pronounced for people with pre-existing diabetes than those without. 

Low‐quality evidence from six trials has not clearly identified the effect of probiotics on the risk of GDM. However, high‐quality evidence suggests that probiotics probably increase the risk of pre‐eclampsia. Therefore, there is currently evidence of possible harm with little observed benefit for widespread use of probiotics in pregnancy. 

https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD009951.pub3/full

Removal of race adjustment may increase CKD diagnoses among Black adults and enhance access to specialist care, medical nutrition therapy, kidney disease education, and kidney transplantation, while potentially excluding kidney donors and prompting drug contraindications or dose reductions for individuals reclassified to advanced stages of CKD.  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7711563/?report=printable

KDIGO Guidelines:  https://kdigo.org/wp-content/uploads/2017/02/KDIGO_2012_CKD_GL.pdf 

This meta-analysis showing a significant reduction in lung cancer– specific mortality, albeit with a tradeoff of likely overdiagnosis, supports recommendations to screen individuals at elevated risk for lung cancer with LDCT.   CT screening .pdf

Screening high-risk persons with LDCT can reduce lung cancer mortality but also causes false-positive results leading to unnecessary tests and invasive procedures, overdiagnosis, incidental findings, increases in distress, and, rarely, radiation-induced cancers. Most studies reviewed did not use current nodule evaluation protocols, which might reduce false-positive results and invasive procedures for false-positive results.  Lung cancer screening USPSTF evidence summary.pdf

Lung Cancer Screening - JAMA editorial.pdf