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

2018-04-11 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 2 1

2018-04-11 Small Adults Big Kids Now Grab Bag What is after after 3 rd line I know you’re sick, just wait Screening CBC test: Steroid shots for Tennis 2 days for these Antibiotics Help or Harm. Elbow for hypertension? MSK Pain in kids, KISS Lipid Guidelines: Back to the Spasm: Ready, Fire, Aim: principles By & For Primary Care Cyclobenzaprine & pain Treating to target Manipulation of the Spine AOM: Who to Treat, Flashes of Evidence for Do sore knees need (and Research) Who to watch Menopauses steroids Lipoproteins & Biomarkers: Sterile wounds: Santa, Kids and Kindness Best rheumatoid lab Test (over)Interpreting “All you need is glove” Overactive Bladder & Rusty Knees, Trial some BMI Honey, I have cough Underactive Medicines Viscous supplementation The secrets of normal Poor Sleep: Chocolate: It tastes so Glucosamine From Swimmer mistake to Don’t go to bed! good, it must good for you. for Rusty Joints rhino-sinusitis cure My infant won’t sleep: Omega-3 & Coffee: Nice Vice or poor Melatonin: Time to train Sleepy time a world without CVD health choice? 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 2

2018-04-11 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 outpatient 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 Simplified Lipid Guideline http://chd.bestsciencemedi cine.com/calc2html#basic Can Fam Physician. 2015;61:857-67. 3

2018-04-11 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.. 4

2018-04-11 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 5

2018-04-11 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. 6

2018-04-11 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 . 7