.EVIDENCE-BASED. .MEDICINE. A Critical Appraisal on Therapeutics March 24, 2022 Clinical Clerk: Bacal, Jose Agerico II P. Avatar: Dr. Krenz Yaba .OBJECTIVES. 1. To present an appraisal of an article on therapeutics using EBM protocol 2. To appraise and determine the relevance, validity and applicability of an article 3. To give a conclusion and a resolution based on the article appraised .CLINICAL SCENARIO. .CASE. Patient JO, a 29 year old man male, Roman Catholic, and a resident of Canito-an, Cagayan de Oro City, came in due to chest pain. .HISTORY OF PRESENT ILLNESS. 12 hours PTC, was working the night shift when he noted onset of chest pain, burning, pain scale 5/10. This was associated with a sour taste on his mouth. There was also noted frequent burping. Patient’s symptoms were temporarily relieved by siing down to rest. Immediately after his shift, persistence of symptoms prompted consult. .PAST MEDICAL. .HISTORY. (-) Hypertension (-) Diabetes Mellitus (+) Bronchial Asthma (Childhood) - Last aack: Unrecalled (-) Malignancy/Cancer (-) Known Allergies (-) Kidney Disease .FAMILY HISTORY. (+) Hypertension - Paternal (-) Diabetes Mellitus - Maternal (-) Bronchial Asthma (-) Malignancy (-) Heart disease (-) Liver/Kidney disease .PERSONAL/SOCIAL. .HISTORY. Single Convenience Store Cashier (-) Smoking (+) Alcoholic Beverage Drinker - 500mL Beer 3-4x/week (-) Drugs .REVIEW OF SYSTEMS. GENERAL (-) loss of appetite (-) weight loss (-) fatigue (-) fever SKIN (-) rashes RESPIRATORY (-) cough (-) dyspnea CARDIOVASCULAR (-) palpitations GIT (-) diarrhea (-) constipation HEENT (-) blurring of vision (-) ear/nasal discharges (-) swollen glands GUT (-) dysuria (-) hematuria (-) urinary frequency (-) lower back pain MUSCULOSKELETAL (-) muscle weakness (-) joint pains (-) diiculty walking NEUROLOGIC (-) seizures .PHYSICAL EXAM. GENERAL: Awake, ambulatory, NIRD VITAL SIGNS: ANTHROPOMETRICS: Height: 140 cm BP: 130/80 mmHg Weight: 50 kgs HR: 98 bpm BMI: 25.5 kg/m2 (Obese Class I) RR: 20 cpm Temp: 36.5 C O2 sat: 99% at room air .PHYSICAL EXAM. SKIN: Brown skin, moist, good turgor HEENT: Anicteric sclerae, Pink palpebral conjunctiva, moist lips and tongue, (-) lymphadenopathy CHEST & LUNGS: Equal chest expansion, Clear breath sounds, (-) retractions .PHYSICAL EXAM. CVS: Adynamic precordium, DHS normal rate, regular rhythm ABDOMEN: Flabby, normoactive bowel sounds, soft, nontender GUT: Grossly male, (-) kidney punch test EXTREMITIES: (-) Bipedal edema, full pulses, CRT <2sec .LABORATORY WORK-UP. K Deficit = 155.56 .ASSESSMENT. 1. Gastroesophageal Reflux Disease 2. Hypokalemia, Mild 3. Malnutrition - Obese Class I .PLAN. HOME MEDICATIONS: 1. Omeprazole tab, 1 tab OD pre-breakfast x 2 weeks 2. Aluminum Hydroxide + Magnesium Hydroxide 200 mg + 200 mg/tab 1 tab TID x 5 days 3. KCl 10 mEq/tab 2 tabs BID x 3 days .PLAN. NON-PHARMACOLOGIC INTERVENTIONS: 1. Avoid acidic food and drinks such as soft drinks and alcoholic beverages 2. Avoid strenuous physical activities 3. Avoid meals within 2-3 hours of bedtime 4. Eat 1 banana per meal 5. Advised .DISCUSSION. .WHAT IS GERD?. ACG Clinical Guideline: Guidelines for the Diagnosis and Management of Gastroesophageal Reflux Disease 2022 .WHAT ARE THE SYMPTOMS OF GERD?. ACG Clinical Guideline: Guidelines for the Diagnosis and Management of Gastroesophageal Reflux Disease 2022 .HOW DO YOU MANAGE GERD?. ACG Clinical Guideline: Guidelines for the Diagnosis and Management of Gastroesophageal Reflux Disease 2022 .ESOMEPRAZOLE. Short‑Term Symptomatic Relief in Gastroesophageal Reflux Disease: A Comparative Study of Esomeprazole and Vonoprazan .VONOPRAZAN. Short‑Term Symptomatic Relief in Gastroesophageal Reflux Disease: A Comparative Study of Esomeprazole and Vonoprazan .EBM STEP 1:. .ASK. .CLINICAL DILEMMA. In adult patients with GERD, will Vonoprazan, compared to Esomeprazole provide beer symptom relief in a randomized controlled trial? .CLINICAL DILEMMA. In adult patients with GERD, will Vonoprazan, compared to Esomeprazole provide beer symptom relief in a randomized controlled trial? .CLINICAL DILEMMA. In adult patients with GERD, will Vonoprazan, compared to Esomeprazole provide beer symptom relief in a randomized controlled trial? .CLINICAL DILEMMA. In adult patients with GERD, will Vonoprazan, compared to Esomeprazole provide beer symptom relief in a randomized controlled trial? .CLINICAL DILEMMA. In adult patients with GERD, will Vonoprazan, compared to Esomeprazole provide beer symptom relief in a randomized controlled trial? .CLINICAL DILEMMA. In adult patients with GERD, will Vonoprazan, compared to Esomeprazole provide beer symptom relief in a randomized controlled trial? .CLINICAL DILEMMA. P Adult patients diagnosed with GERD I Vonoprazan C Esomeprazole O Beer relief of symptoms M Randomized Controlled Trial .EBM STEP 2:. .ACQUIRE. .SEARCHING THE LITERATURE. .EBM STEP 3:. .APPRAISE. .R. .ELEVANCE. Is the objective of the article comparing therapeutic interventions to the clinical dilemma? .R. .ELEVANCE. .CLINICAL SCENARIO. .JOURNAL SCENARIO. Adult patients diagnosed with GERD Adult Patients diagnosed with GERD Vonoprazan Vonoprazan 20 mg/day administered over 4 weeks C Esomeprazole Esomeprazole 20 mg/day administered over 4 weeks O Beer relief of symptoms Significantly beer GerdQ, FSSG, and GOS scores M Randomized Controlled Trial Randomized Controlled Trial P I .R. .ELEVANCE. Is the objective of the article comparing therapeutic interventions to the clinical dilemma? YES .V. .ALIDITY. Was the assignment of patients to treatment groups randomized? .V. .ALIDITY. .V. .ALIDITY. Was the assignment of patients to treatment groups randomized? YES .V. .ALIDITY. Was follow-up rate adequate? .V. .ALIDITY. .V. .ALIDITY. Was follow-up rate adequate? YES .V. .ALIDITY. Were baseline characteristics similar at the start of the trial? .V. .ALIDITY. .V. .ALIDITY. Were baseline characteristics similar at the start of the trial? YES .V. .ALIDITY. Were patients blinded to treatment assignment? Were clinicians “blind” to treatment? Was the study personnel “blind” to treatment? .V. .ALIDITY. .V. .ALIDITY. Were patients blinded to treatment assignment? Were clinicians “blind” to treatment? Was the study personnel “blind” to treatment? NO .V. .ALIDITY. Aside from the experimental intervention, were the groups treated equally? .V. .ALIDITY. .V. .ALIDITY. Aside from the experimental intervention, were the groups treated equally? YES .V. .ALIDITY. Overall, is the study valid? .V. .ALIDITY. Overall, is the study valid? YES .R. .ESULTS. How large was the treatment eect? .R. .ESULTS. .R. .ESULTS. .CONTROL. .INTERVENTION. Esomeprazole 20 mg/tab OD n = 25 88.0% * 25 = 22 treated 25 - 22 = 3 not treated Rc = 3/25 = 0.12 Vonoprazan 20 mg/tab OD n = 22 81.8% * 22 = 18 treated 22 - 18 = 4 not treated Rt = 4/22 = 0.18 .R. .ESULTS. .CONTROL. .INTERVENTION. Esomeprazole 20 mg/tab OD Vonoprazan 20 mg/tab OD Rc = 3/25 = 0.12 Rt = 4/22 = 0.18 RR ARR RRR NNT Rt/Rc = 0.18/0.12 Rc - Rt = 0.12 - 0.18 = -0.06 1 - RR = 1 - 1.5 = -0.5 1/ARR = 100/-6% = 1.5 = -6% = -50% = -16.67 .R. .ESULTS. How large was the treatment eect? HARMFUL .EBM STEP 4:. .APPLY. .A. .PPLICABILITY. Can the results be applied to my patient care? YES .A. .PPLICABILITY. Were all clinically important outcomes considered? YES .A. .PPLICABILITY. Is the likely treatment worth the potential harm and costs? NO .EBM STEP 5:. .ASSESS. .RESOLUTION. In adult patients with GERD, Vonoprazan, compared to Esomeprazole, in providing beer symptom relief, will be harmful.
