Fact vs Fictions
Evidence Based Medicine-? A Moving Target
The Newest Trends=Evidence
Pearls of Practice 2012
Objectives:
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At the end of this program you should be better able to:
Recognize more of what is currently recommended in various
areas of patient care-realize “best practices” can change rapidlythat the MD must keep up as difficult as that may be.
Appreciate best recommendations come from unbiased met
analysis-many studies of the same subject-not a single paper.
Recognize the need to communicate to patients the scope of
what is currently advised as “best practice”, (give the pros and
cons).
Buy a good lunch, after getting a free breakfast
Disclosure
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I do not have any significant financial
disclosures to disclose.
Pre-Test Questions
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True or False: Use of lipid lowering drugs in adults with normal
lipids as a preventative measure, and in children, is a good idea.
True or False: Peanut butter applied to the back can be
associated with relief of pain 90% of the time over 3-6 months.
True or False: Bed rest of a week or more is required for fastest
improvement of acute back pain.
True of False: Ambien or similar sedative is the best treatment for
insomnia in the elderly.
True or False: Ankle edema associated with a sprain, medicine
wise, is best treated with a Motrin, Voltaren or Celebrex.
True or False: Steroid joint injections should always be done with
ultrasound guidance.
True or False: All diabetics should be treated to a Hgaic level of
7%.
True or False: These questions are stupid.
Facts vs. Fictions
Evidence Based Medicine-? A Moving Target
The Newest Trends in=Evidence
Patient Satisfaction surveys-new standard to
evaluate health care businesses and doctors. Most
satisfied patients had 12% more admissions, 9%
more health care expenditures and used more
drugs, and 26% higher mortality than less satisfied
patients.
Obesity in infants/children:
More in formular feed than breast feed and
more if given solids before age 4 months.
C-Sections
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Increasing but the indications for these are
not.
Convenience factor?
Lactobacillus Rueters
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5 drops of Lactobacillus Rueters given AM
before feeding decreases colic episodes by
41%
Lactobacillus Acidophilus
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Lactobacillus Acidophilus given daily age 3-5
years cut fever and cough episodes by 50%
and antibiotic use by 66%.
Lipid Lowering Drugs
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Use of lipid (LDL) lowering drugs in children
as proposed by the American Academy of
Pediatrics 3 years ago not felt appropriatefew get to suggested goal and cost and side
effects of meds significant-no evidence so far
is associated with better health
cardiovascular wise.
Treating Lipids
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Treating lipids in patients as a preventative
measure-patient with no evidence of risks or
of heart disease does not decrease mortalitydiet and exercise do.
HDL
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Increasing HDL with niacin has no effect on
mortality of patients with heart disease.
Treating Lipids with Fibrates
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Treating lipids with fibrates (lopid and tricor)
to lower triglycerides does not lower the risk
of cardiovascular disease as studied over 8
years.
Statins
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Statin use may increase risk of diabetes-in
addition to risk of myopathy and liver enzyme
increases and use in patient with no heart
disease suggested not appropriate.
Cognitive Behavior Therapy
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Cognitive Behavior Therapy=teaching
patients with recent heart attack to think good
thoughts and positive thoughts and exercise
to tolerance-done in 20 sessions of 2 hours
over 8 years cuts rate of recurrent heart
attack to one in 3 compared to one in 2 in the
usual care group in a published article.
NSAID
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NSAID use increases risk of death or new
heart attack in patients with prior heart attack
by 50%. Felt to increase risk of CVA or heart
attack in all past age 65.
Defibrillators
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20% of implanted cardiac defibrillators felt not
indicated-not advised used within 40 days of
an infarct or during recovery from CABG or in
patient with class 4 heart failure-may
increase risk of death in these circumstances.
Back-Ache Pain
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X-ray of lower back in patient with acute back
ache-unless associated with severe trauma
or fever or weight loss or night pain no help.
MRI or CT myelogram best if surgery is being
considered after 6-12 weeks.
Only 5-10% of low back pain persists after 6
months even if no treatment given.
Opioids
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Avoid opiods-especially oxycotin-as pain med
for back or other pains-highly addictive-84%
increase in deaths due to use of prescription
given opiods reported over last 8-10 years.
Is leading cause of death ages 25-55
Death 4 times more common than from illicit
drug use.
? Given frequently by ER’s-? To get good
patient satisfaction ratings.
Titles that Mislead
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18% of published papers have titles that misleadsuggest a Positive outcome of a trial of a therapy
not supported by documentation. The truth may be
distorted in the conclusion. Conflicts of interest are
important to note. Negative trails are not generally
reported. Note the authors of studies on
controversial screening recommendations. Does
the author have a financial interest at stake if a
recommendation will affect his profit making
potential.
Pap Tests
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Pap tests are not felt needed under age 21
then q 2 years to mid or late 30’s, then q 10
years if all negative, and then not after age
65-70.
Screening Bone Density
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Screening bone density suggested started
after age 65. If no increased risk of
osteoporosis e.g. patient on steroid, past
non-traumatic fracture, a smoker, thin, family
history of excess fractures. Can be repeated
every 5-10 years as screen.
Alendronate (fosamax)
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Alendronate (fosamax) decreases hip and
vertebral fractures if bone density at hip <2.5.
(long term use may lead to low energy fx
femoral neck-osteonecrosis of jaw).
Estrogen use decreases hip fracture and
vertebral fractures-may increase risk of clots
Forteo and estrace reduce verebral fracturesnot hip fractures.
Estrogen
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Estrogen may increase risk of breast cancer
and heart disease.
Insomnia
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Elderly with insomnia do better if advised to
go to bed only when sleepy and to get up
when not sleepy.
55% improved to having no problem with this
approach compared with 13% given a
sedative e.g. Ambien (has been associated
with an increased risk of various cancers).
Phentermine, Topamax, Naltrexone and
Wellbutrin
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Phentermine combined with Topamax and
Naltrexone combined with Wellbutrin have
been approved for weight loss help-use
resulted in 23+ pound loss in a year-? Any
better than past products as help to sustain
loss-no severe side effects reported.
Exercise important. Sitting watching TV>2
hours/day in one study reported increased
risk of diabetes, heart attack, and all cause
mortality.
Humidifiers
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Humidifiers do not increase incidence of
respiratory illnesses in the winter.
Prednisone
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Prednisone use lead to lower ventilator use, lower
death rate and lower readmission rate when
compared to similar degree of illness of patients
treated in hospital with IV steriods. Hospital stays
shorter in prednisone group as well.
60 mgm of prednisone daily x 5 days or 16 mgm
poqd of decadron x 2 days improved 90% of
moderately severe asthmatics.
Acute severe pnuemonia patients treated with
decadron x 4 days had no adverse events and cut
one day off the hospital stay.
Tylenol
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Tylenol given for ankle sprain with tear of
lateral ligament was as effective for pain relief
and reduced edema better when compared to
use of a NSAID instead.
Steroid Injections
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A Steroid injected with ultrasound assistance
into a join hit the target 83% of the time in a
study that compared this with a steroid
injected into a joint area without use of
ultrasound-hit the target 66% of time.
At the end of 2 weeks and 6 weeks post
treatment symptom relief was the same.
Cell Phones and Cancer
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Cell phones do not significantly increase the
risk of brain cancer-this per British study
2006. If used 30+ minutes/day same side of
head X10 years increased incidence of brain
tumor from 1 in 200,000 to one in 80,000 in
another study. Cell phones increased risk of
MVA x4 if used while driving-similar to blood
alcohol of 0.8.
Blood Sugar Control
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Tight control of blood sugars in older diabetics with long standing
problem no proven help. May harm with increased hypoglycemic
episodes. This true with oral agents or insulin. ACCORD,
ADVANCE, VADT studies and others found no decrease in
mortality, CVAs, heart attacks, amputations etc with tight control.
Some say results would be better if tight control started 10 years
before the patients studied.
British study 1999 found newly diagnosed diabetes tightly
controlled showed no improvement in all cause mortality,
cardiovascular mortality, diabetes related mortality. Metformin
lowered mortality. Metformen + a sulfonylurea or insulin did not.
Some have suggested a Hgaic 7-9% ok in older type 2 diabetes.
PSA
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PSA should be done as a screening after
discussion with patient about possible
consequences of a + result-this is at any ageand not after age 75.
In past suggested done on all age 50 and
up-some ethnic groups (African Americans)
sooner.
Colonoscopy Screening
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Colonoscopy screening suggested age 50
and q 10 years-some patients have been told
q 7 years.
Mamograms
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? Mamograms suggested q 2 years and stop
age 75.
Medical Statistics
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Joe Qeenan wrote in the Wall Street Journal May 12: Needed-a Cure
for Medical Statistics.
Joe had read obese fliers were at risk of seat belt failures-had planned
trip to Las Vegas-was overweight. Decided to diet-starting eating
yogurt instead of pancakes and sausage at breakfast.
Read yogurt high in calories and a silent killer.
Started low fat muffins instead-read these had high calories also and
low
Cholesterol can cause cancer, anxiety and depression.
Was going to start antidepressant but read these made ineffective by
pain killer he uses for neck pain.
Started eating granola bars-read high in sugar-could cause prediabetes or diabetes, especially if eaten fast.
Read Las Vegas was experimenting with driverless cars on their
streets.
Decided to stay home.
Bottom Line:
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Don’t believe everything you see or hear.
What is gospel today may be heresy
tomorrow.