Tools for Practice

Tools for Practice articles have been produced by the PEER team in collaboration with the ACFP since 2009.
Click here for the entire collection

Recent Tools for Practice

Tools for Practice #269 – Osteoarthritis pain getting you down? Duloxetine

Do Serotonin Norepinephrine Reuptake Inhibitors (SNRIs), specifically duloxetine, improve pain in patients with osteoarthritis?

Bottom Line: Duloxetine can meaningfully reduce osteoarthritis pain scores (by at least 30%) for ~60% of patients compared to ~40% on placebo. An average pain of ~6 (scale 0-10) will be reduced by ~2.5 points, compared to 1.7 on placebo. Duloxetine adverse effects lead to withdrawal in 12% of patients versus 6% on placebo.  Read More

Tools for Practice #268 – Is 45 really the new 50 in colorectal cancer screening?

Should we lower the age that average risk patients commence colorectal cancer screening from 50 to 45?

In developed countries, the incidence of colorectal cancer in persons under 50 years old has increased by 20-30% in the last 20 years. However, the absolute risk increase is only 1-4 per 100,000 persons. Screening average risk patients under age 50 should not be encouraged at this time. Read More

Tools for Practice #267 – Serology, Serology: How Accurate and Prevalent Art Thou?

What is the role of serology testing in the COVID-19 pandemic?

Bottom Line: IgM and IgG antibodies may reveal an individual's recent (after ~2 weeks) exposure to COVID-19. How long serology remains positive and whether antibodies confer immunity to subsequent infection is unknown. Many different tests exist, each with different accuracy. Current evidence does not support routine use of serology testing in COVID-19 management.    Read More

Tools for Practice #266 – Exercise-induced osteoarthritis: Running into problems?

Does running increase the risk of developing osteoarthritis?

Bottom Line: Based on low-quality observational data, running likely does not increase the risk of developing osteoarthritis, except possibly in elite athletes. Additionally, recreational running may be associated with lowering the risk of knee osteoarthritis. Exercise is one of the most effective treatments for reducing osteoarthritic pain. Read More

Tools for Practice #265 – “Does baby know best?”: Benefits and harms of baby-led weaning for transitioning to solid foods

What impact does baby-led weaning have on infant growth, iron intake, and choking?

Bottom Line: Transitioning infants to solid foods using a baby-led weaning approach (with parental education) results in up to 0.7kg less weight gain at 12 months than traditional spoon feeding. This is of unknown clinical significance. There is no difference in iron intake or choking episodes. Read More

PEER Picks

#255 – Exercise for osteoarthritis pain: how strong is the evidence?

Is exercise effective for pain management in hip/knee osteoarthritis?

Read More

#250 – DPP-4 inhibitor update: Thousands studied but still no evidence of clinical benefits

In type 2 diabetes, do dipeptidyl peptidase-4 (DPP-4) inhibitors improve patient-oriented outcomes like cardiovascular disease (CVD)?

Read More

#238 – In COPD puffers, does three-of-kind beat a pair?

In Chronic Obstructive Pulmonary Disease (COPD) patients on Long-Acting Muscarinic Antagonist (LAMA) and Long-Acting Beta-Agonist (LABA) dual therapy, does adding inhaled corticosteroids (ICS) improve outcomes?

Read More

Tools for Practice by Catagory

Anesthesiology

(3)

#244 – Injecting Evidence into Platelet-Rich Plasma Injections

Bottom Line: The best quality evidence shows no difference in pain, function, or return to sport between platelet-rich plasma, dry needling, or saline for patients with Achilles tendinopathy, lateral epicondylitis, or rotator cuff tendinopathy.

Read Tool

#243 – Spread the Word: Widespread Distribution of Naloxone to Decrease Opioid-Related Deaths

Bottom Line: Offering naloxone kits and overdose related education for people who use opioids and their community may decrease opioid related deaths by ~7 per 100,000 population over one year. Effectiveness is likely influenced by magnitude of opioid problem in a given community and other confounders (like co-ingestions, co-morbidities, type and dose of opioid used).

Read Tool

#240 – What is the Incidence of Iatrogenic Opioid Use Disorder?

Bottom Line: The incidence of OUD associated with prescribed opioids among chronic pain patients is likely ~3% (over ~2 years) but causation is uncertain. Patients with no history of substance use disorders appear to be at lower risk (<1%). Factors associated with increased risk of OUD include a history of substance use disorder and receiving opioids for longer duration (>90 days) or at higher doses (>120mg/day morphine equivalent).

Read Tool
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Cardiology

(8)

#264 – From theory to reality: ACEi, ARB, and COVID-19

Bottom Line: Despite initial theoretical suggestions that ACEi and ARB are harmful, four observational studies have since found no association between COVID-19 infection or severity of disease and ACEi/ARB. One cohort study with the smallest number of COVID-19 patients found an association between ACEi, ARB and hospitalization but not mechanical ventilation. All studies have limitations associated with observational studies including potential confounders and bias which require imperfect statistical adjustments.

Read Tool

#262 – Who let the Gout Out? Targeting Uric Acid Levels in Treating Gout

Bottom Line: Best evidence finds that increasing doses of allopurinol to achieve a specific serum urate target (example <360 μmol/L) does not reduce gout flares, pain, or function, compared to standard allopurinol dosing. Febuxostat increases cardiovascular and overall mortality and should not be used in most patients with gout.

Read Tool

#258 – Stealth style transmission? Covert data on COVID-19

Bottom Line: Transmission of COVID-19 can occur in people who are currently asymptomatic. Case reports suggest this occurs in 6-13% of cases, although modelling suggests this might be higher. The importance of asymptomatic transmission is heightened by reports that ~50% of carriers are asymptomatic when an entire population (example cruise ship) is tested. Physical distancing should assist in preventing transmission from asymptomatic individuals.

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#257 – A rushed introduction to an uninvited guest

Bottom Line: Cough and fever are the most common symptoms. Differences in testing and reporting of cases limit prognostic estimations. At minimum, 80% of cases are clinically mild. Of those hospitalized in North America, ~25% will require ICU admission. Risk factors for mortality include age >65 years, co-morbidities, long-term care residents, and those with COVID-19 associated cardiac injury.

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#248 – Hydrochlorothiazide and Squamous Cell Skin Cancer: Remember when hypertension was easy?

Bottom Line: Observational data suggest an association between hydrochlorothiazide and the risk of SCC. Causation has not been proven. Risk appears to consistently increase with dose and duration (example: 5 years of use increases risk 3-4 times). Baseline incidence of SCC is <0.1% annually. The same risk has not been established with thiazide-like diuretics (like indapamide or chlorthalidone). The benefit of switching from hydrochlorothiazide to another agent should be weighed against the risk of changing medications.

Read Tool
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Chronic Pain

(5)

#269 – Osteoarthritis pain getting you down? Duloxetine

Bottom Line: Duloxetine can meaningfully reduce osteoarthritis pain scores (by at least 30%) for ~60% of patients compared to ~40% on placebo. An average pain of ~6 (scale 0-10) will be reduced by ~2.5 points, compared to 1.7 on placebo. Duloxetine adverse effects lead to withdrawal in 12% of patients versus 6% on placebo. 

Read Tool

#266 – Exercise-induced osteoarthritis: Running into problems?

Bottom Line: Based on low-quality observational data, running likely does not increase the risk of developing osteoarthritis, except possibly in elite athletes. Additionally, recreational running may be associated with lowering the risk of knee osteoarthritis. Exercise is one of the most effective treatments for reducing osteoarthritic pain.

Read Tool

#244 – Injecting Evidence into Platelet-Rich Plasma Injections

Bottom Line: The best quality evidence shows no difference in pain, function, or return to sport between platelet-rich plasma, dry needling, or saline for patients with Achilles tendinopathy, lateral epicondylitis, or rotator cuff tendinopathy.

Read Tool

#243 – Spread the Word: Widespread Distribution of Naloxone to Decrease Opioid-Related Deaths

Bottom Line: Offering naloxone kits and overdose related education for people who use opioids and their community may decrease opioid related deaths by ~7 per 100,000 population over one year. Effectiveness is likely influenced by magnitude of opioid problem in a given community and other confounders (like co-ingestions, co-morbidities, type and dose of opioid used).

Read Tool

#240 – What is the Incidence of Iatrogenic Opioid Use Disorder?

Bottom Line: The incidence of OUD associated with prescribed opioids among chronic pain patients is likely ~3% (over ~2 years) but causation is uncertain. Patients with no history of substance use disorders appear to be at lower risk (<1%). Factors associated with increased risk of OUD include a history of substance use disorder and receiving opioids for longer duration (>90 days) or at higher doses (>120mg/day morphine equivalent).

Read Tool
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Dermatology

(3)

#248 – Hydrochlorothiazide and Squamous Cell Skin Cancer: Remember when hypertension was easy?

Bottom Line: Observational data suggest an association between hydrochlorothiazide and the risk of SCC. Causation has not been proven. Risk appears to consistently increase with dose and duration (example: 5 years of use increases risk 3-4 times). Baseline incidence of SCC is <0.1% annually. The same risk has not been established with thiazide-like diuretics (like indapamide or chlorthalidone). The benefit of switching from hydrochlorothiazide to another agent should be weighed against the risk of changing medications.

Read Tool

#242 – Putting the FUN in Fungi: Toenail onychomycosis treatments

Bottom Line: Up to 45-60% of patients on oral treatments (terbinafine best), 6-23% on topicals (efinaconazole best), and <10% on placebo will be “cured” after ~1 year. Topicals should be reserved for cases with minimal (≤20-40%) nail involvement.

Read Tool

#241 – “Who’s the fairest of them all?”: Topical treatments for rosacea

Bottom Line: For moderate-severe papulopustular rosacea, topical metronidazole, azelaic acid, and ivermectin have similar benefit with ~65-75% achieving patient reported improvement

Read Tool
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Emergency

(12)

#267 – Serology, Serology: How Accurate and Prevalent Art Thou?

Bottom Line: IgM and IgG antibodies may reveal an individual's recent (after ~2 weeks) exposure to COVID-19. How long serology remains positive and whether antibodies confer immunity to subsequent infection is unknown. Many different tests exist, each with different accuracy. Current evidence does not support routine use of serology testing in COVID-19 management.   

Read Tool

#264 – From theory to reality: ACEi, ARB, and COVID-19

Bottom Line: Despite initial theoretical suggestions that ACEi and ARB are harmful, four observational studies have since found no association between COVID-19 infection or severity of disease and ACEi/ARB. One cohort study with the smallest number of COVID-19 patients found an association between ACEi, ARB and hospitalization but not mechanical ventilation. All studies have limitations associated with observational studies including potential confounders and bias which require imperfect statistical adjustments.

Read Tool

#263 – Finding COVID – How Good is the Test to Detect it?

Bottom Line: If the PCR COVID-19 test is positive you have COVID-19 (specificity ~100%). Small Canadian studies suggest the test will detect COVID-19 ~80-90% of the time (sensitivity), although estimates range from ~50%-90%. Collection technique, anatomical sample and timing of collection influence these numbers. The chance of a false negative depends on sensitivity and the pre-test probability the person has COVID-19. Example: someone with abnormal chest x-rays and close COVID-19 positive contacts has a higher risk of false negatives than someone who is asymptomatic.     

Read Tool

#261 – Antivirals for COVID-19

Bottom Line: To date, published RCTs have not demonstrated benefit of treating COVID-19 patients with remdesivir, lopinavir-ritonavir or oseltamivir.  There are signals of potential benefits from one interim analysis of remdesivir and non-statistically different results, but more research is needed. Full publication of studies and ongoing trials will help to answer this question.    

Read Tool

#260 – Are there tools to help assess dyspnea virtually?

Bottom Line: Unfortunately, no specific technique, including the Roth Score, is reliable in assuring dyspneic patients are not at risk and safe to stay home. Furthermore, no studies have evaluated dyspnea assessment in COVID-19 patients. Clinicians are encouraged to use available tools (https://www.bmj.com/content/368/bmj.m1182/infographic) and have patients assessed in-person if there are any concerns. 

Read Tool
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Endocrinology

(3)

#247 – Fact or Fad: Intermittent fasting for sustained weight loss

Bottom Line: Although inconsistently defined, intermittent fasting (example 500 kcal/day for 2 days/week) and continuous dieting (~25% reduction in caloric intake daily) result in similar weight loss, usually ~5-9kg at 6 months-1 year. Discontinuation rates with both diets is up to ~60%.

Read Tool

#245 – Taking a hard look at the evidence: Phosphodiesterase-5-inhibitors in erectile dysfunction

Bottom Line: PDE5 inhibitors increase the proportion of successful sexual intercourse attempts to ~65% versus ~30% for placebo. For every 3 men given a PDE5 inhibitor compared to placebo, an additional 1 will have “improved erections”.

Read Tool

#239 – Need milk? Domperidone for increasing breast milk supply

Bottom Line: In mothers of pre-term infants, domperidone increases milk volume by ~90 ml more than placebo after 14 days, with an additional 1 in 5 women experiencing a 50% increase in milk supply. Doses above 30 mg/day are likely not needed and may increase the risk of arrhythmias. Optimal length of treatment unknown.

Read Tool
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Gastroenterology

(3)

#268 – Is 45 really the new 50 in colorectal cancer screening?

In developed countries, the incidence of colorectal cancer in persons under 50 years old has increased by 20-30% in the last 20 years. However, the absolute risk increase is only 1-4 per 100,000 persons. Screening average risk patients under age 50 should not be encouraged at this time.

Read Tool

#247 – Fact or Fad: Intermittent fasting for sustained weight loss

Bottom Line: Although inconsistently defined, intermittent fasting (example 500 kcal/day for 2 days/week) and continuous dieting (~25% reduction in caloric intake daily) result in similar weight loss, usually ~5-9kg at 6 months-1 year. Discontinuation rates with both diets is up to ~60%.

Read Tool

#236 – It’s all in the details… or is it? Biosimilars versus biologics for inflammatory conditions

Bottom Line: For patients with rheumatoid arthritis, other inflammatory arthropathies, or inflammatory bowel disease, biosimilars and biologics have similar clinical outcomes and adverse events. Given the cost differences, starting patients with or switching to biosimilars should be encouraged.

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General

(27)

#269 – Osteoarthritis pain getting you down? Duloxetine

Bottom Line: Duloxetine can meaningfully reduce osteoarthritis pain scores (by at least 30%) for ~60% of patients compared to ~40% on placebo. An average pain of ~6 (scale 0-10) will be reduced by ~2.5 points, compared to 1.7 on placebo. Duloxetine adverse effects lead to withdrawal in 12% of patients versus 6% on placebo. 

Read Tool

#268 – Is 45 really the new 50 in colorectal cancer screening?

In developed countries, the incidence of colorectal cancer in persons under 50 years old has increased by 20-30% in the last 20 years. However, the absolute risk increase is only 1-4 per 100,000 persons. Screening average risk patients under age 50 should not be encouraged at this time.

Read Tool

#267 – Serology, Serology: How Accurate and Prevalent Art Thou?

Bottom Line: IgM and IgG antibodies may reveal an individual's recent (after ~2 weeks) exposure to COVID-19. How long serology remains positive and whether antibodies confer immunity to subsequent infection is unknown. Many different tests exist, each with different accuracy. Current evidence does not support routine use of serology testing in COVID-19 management.   

Read Tool

#266 – Exercise-induced osteoarthritis: Running into problems?

Bottom Line: Based on low-quality observational data, running likely does not increase the risk of developing osteoarthritis, except possibly in elite athletes. Additionally, recreational running may be associated with lowering the risk of knee osteoarthritis. Exercise is one of the most effective treatments for reducing osteoarthritic pain.

Read Tool

#265 – “Does baby know best?”: Benefits and harms of baby-led weaning for transitioning to solid foods

Bottom Line: Transitioning infants to solid foods using a baby-led weaning approach (with parental education) results in up to 0.7kg less weight gain at 12 months than traditional spoon feeding. This is of unknown clinical significance. There is no difference in iron intake or choking episodes.

Read Tool
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  • 6

General Surgery

(2)

#248 – Hydrochlorothiazide and Squamous Cell Skin Cancer: Remember when hypertension was easy?

Bottom Line: Observational data suggest an association between hydrochlorothiazide and the risk of SCC. Causation has not been proven. Risk appears to consistently increase with dose and duration (example: 5 years of use increases risk 3-4 times). Baseline incidence of SCC is <0.1% annually. The same risk has not been established with thiazide-like diuretics (like indapamide or chlorthalidone). The benefit of switching from hydrochlorothiazide to another agent should be weighed against the risk of changing medications.

Read Tool

#240 – What is the Incidence of Iatrogenic Opioid Use Disorder?

Bottom Line: The incidence of OUD associated with prescribed opioids among chronic pain patients is likely ~3% (over ~2 years) but causation is uncertain. Patients with no history of substance use disorders appear to be at lower risk (<1%). Factors associated with increased risk of OUD include a history of substance use disorder and receiving opioids for longer duration (>90 days) or at higher doses (>120mg/day morphine equivalent).

Read Tool
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  • 1

Geriatrics

(1)

#240 – What is the Incidence of Iatrogenic Opioid Use Disorder?

Bottom Line: The incidence of OUD associated with prescribed opioids among chronic pain patients is likely ~3% (over ~2 years) but causation is uncertain. Patients with no history of substance use disorders appear to be at lower risk (<1%). Factors associated with increased risk of OUD include a history of substance use disorder and receiving opioids for longer duration (>90 days) or at higher doses (>120mg/day morphine equivalent).

Read Tool
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  • 1
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  • 1

Hematology

(2)

#242 – Putting the FUN in Fungi: Toenail onychomycosis treatments

Bottom Line: Up to 45-60% of patients on oral treatments (terbinafine best), 6-23% on topicals (efinaconazole best), and <10% on placebo will be “cured” after ~1 year. Topicals should be reserved for cases with minimal (≤20-40%) nail involvement.

Read Tool

#241 – “Who’s the fairest of them all?”: Topical treatments for rosacea

Bottom Line: For moderate-severe papulopustular rosacea, topical metronidazole, azelaic acid, and ivermectin have similar benefit with ~65-75% achieving patient reported improvement

Read Tool
  • Page
  • 1
  • of
  • 1

Infectious Disease

(10)

#267 – Serology, Serology: How Accurate and Prevalent Art Thou?

Bottom Line: IgM and IgG antibodies may reveal an individual's recent (after ~2 weeks) exposure to COVID-19. How long serology remains positive and whether antibodies confer immunity to subsequent infection is unknown. Many different tests exist, each with different accuracy. Current evidence does not support routine use of serology testing in COVID-19 management.   

Read Tool

#264 – From theory to reality: ACEi, ARB, and COVID-19

Bottom Line: Despite initial theoretical suggestions that ACEi and ARB are harmful, four observational studies have since found no association between COVID-19 infection or severity of disease and ACEi/ARB. One cohort study with the smallest number of COVID-19 patients found an association between ACEi, ARB and hospitalization but not mechanical ventilation. All studies have limitations associated with observational studies including potential confounders and bias which require imperfect statistical adjustments.

Read Tool

#263 – Finding COVID – How Good is the Test to Detect it?

Bottom Line: If the PCR COVID-19 test is positive you have COVID-19 (specificity ~100%). Small Canadian studies suggest the test will detect COVID-19 ~80-90% of the time (sensitivity), although estimates range from ~50%-90%. Collection technique, anatomical sample and timing of collection influence these numbers. The chance of a false negative depends on sensitivity and the pre-test probability the person has COVID-19. Example: someone with abnormal chest x-rays and close COVID-19 positive contacts has a higher risk of false negatives than someone who is asymptomatic.     

Read Tool

#261 – Antivirals for COVID-19

Bottom Line: To date, published RCTs have not demonstrated benefit of treating COVID-19 patients with remdesivir, lopinavir-ritonavir or oseltamivir.  There are signals of potential benefits from one interim analysis of remdesivir and non-statistically different results, but more research is needed. Full publication of studies and ongoing trials will help to answer this question.    

Read Tool

#260 – Are there tools to help assess dyspnea virtually?

Bottom Line: Unfortunately, no specific technique, including the Roth Score, is reliable in assuring dyspneic patients are not at risk and safe to stay home. Furthermore, no studies have evaluated dyspnea assessment in COVID-19 patients. Clinicians are encouraged to use available tools (https://www.bmj.com/content/368/bmj.m1182/infographic) and have patients assessed in-person if there are any concerns. 

Read Tool
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Neurology

(1)

#240 – What is the Incidence of Iatrogenic Opioid Use Disorder?

Bottom Line: The incidence of OUD associated with prescribed opioids among chronic pain patients is likely ~3% (over ~2 years) but causation is uncertain. Patients with no history of substance use disorders appear to be at lower risk (<1%). Factors associated with increased risk of OUD include a history of substance use disorder and receiving opioids for longer duration (>90 days) or at higher doses (>120mg/day morphine equivalent).

Read Tool
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Obstetrics-Gynecology

(2)

#238 – In COPD puffers, does three-of-kind beat a pair?

Bottom Line: In COPD patients with ≥1 exacerbation per year, triple therapy reduces the risk of having ≥1 exacerbations/year compared to LAMA/LABA dual therapy (one less patient for every 36) but increases the risk of pneumonia (one more patient for every 34) and costs. It is possible that higher blood eosinophil counts (>150-300 cells/µL) may help target adding ICS.

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#237 – Verifying the Value of Vaginal Estradiol Tablets

Bottom Line: Vaginal estradiol tablets are likely no better than placebo vaginal gel for reducing “most bothersome symptom scores” (mainly dyspareunia). However, compared to placebo vaginal tablets, they reduce symptoms (example: treatment “success” at 12 months in 86% versus 41% placebo). A non-medicated vaginal gel may be reasonable first-line for dyspareunia.

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Oncology

(2)

#268 – Is 45 really the new 50 in colorectal cancer screening?

In developed countries, the incidence of colorectal cancer in persons under 50 years old has increased by 20-30% in the last 20 years. However, the absolute risk increase is only 1-4 per 100,000 persons. Screening average risk patients under age 50 should not be encouraged at this time.

Read Tool

#248 – Hydrochlorothiazide and Squamous Cell Skin Cancer: Remember when hypertension was easy?

Bottom Line: Observational data suggest an association between hydrochlorothiazide and the risk of SCC. Causation has not been proven. Risk appears to consistently increase with dose and duration (example: 5 years of use increases risk 3-4 times). Baseline incidence of SCC is <0.1% annually. The same risk has not been established with thiazide-like diuretics (like indapamide or chlorthalidone). The benefit of switching from hydrochlorothiazide to another agent should be weighed against the risk of changing medications.

Read Tool
  • Page
  • 1
  • of
  • 1

Orthopedics

(1)

#240 – What is the Incidence of Iatrogenic Opioid Use Disorder?

Bottom Line: The incidence of OUD associated with prescribed opioids among chronic pain patients is likely ~3% (over ~2 years) but causation is uncertain. Patients with no history of substance use disorders appear to be at lower risk (<1%). Factors associated with increased risk of OUD include a history of substance use disorder and receiving opioids for longer duration (>90 days) or at higher doses (>120mg/day morphine equivalent).

Read Tool
  • Page
  • 1
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  • 1

Pediatrics

(2)

#265 – “Does baby know best?”: Benefits and harms of baby-led weaning for transitioning to solid foods

Bottom Line: Transitioning infants to solid foods using a baby-led weaning approach (with parental education) results in up to 0.7kg less weight gain at 12 months than traditional spoon feeding. This is of unknown clinical significance. There is no difference in iron intake or choking episodes.

Read Tool

#239 – Need milk? Domperidone for increasing breast milk supply

Bottom Line: In mothers of pre-term infants, domperidone increases milk volume by ~90 ml more than placebo after 14 days, with an additional 1 in 5 women experiencing a 50% increase in milk supply. Doses above 30 mg/day are likely not needed and may increase the risk of arrhythmias. Optimal length of treatment unknown.

Read Tool
  • Page
  • 1
  • of
  • 1

Psychiatry

(2)

#243 – Spread the Word: Widespread Distribution of Naloxone to Decrease Opioid-Related Deaths

Bottom Line: Offering naloxone kits and overdose related education for people who use opioids and their community may decrease opioid related deaths by ~7 per 100,000 population over one year. Effectiveness is likely influenced by magnitude of opioid problem in a given community and other confounders (like co-ingestions, co-morbidities, type and dose of opioid used).

Read Tool

#240 – What is the Incidence of Iatrogenic Opioid Use Disorder?

Bottom Line: The incidence of OUD associated with prescribed opioids among chronic pain patients is likely ~3% (over ~2 years) but causation is uncertain. Patients with no history of substance use disorders appear to be at lower risk (<1%). Factors associated with increased risk of OUD include a history of substance use disorder and receiving opioids for longer duration (>90 days) or at higher doses (>120mg/day morphine equivalent).

Read Tool
  • Page
  • 1
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  • 1

Pulmonology

(7)

#264 – From theory to reality: ACEi, ARB, and COVID-19

Bottom Line: Despite initial theoretical suggestions that ACEi and ARB are harmful, four observational studies have since found no association between COVID-19 infection or severity of disease and ACEi/ARB. One cohort study with the smallest number of COVID-19 patients found an association between ACEi, ARB and hospitalization but not mechanical ventilation. All studies have limitations associated with observational studies including potential confounders and bias which require imperfect statistical adjustments.

Read Tool

#263 – Finding COVID – How Good is the Test to Detect it?

Bottom Line: If the PCR COVID-19 test is positive you have COVID-19 (specificity ~100%). Small Canadian studies suggest the test will detect COVID-19 ~80-90% of the time (sensitivity), although estimates range from ~50%-90%. Collection technique, anatomical sample and timing of collection influence these numbers. The chance of a false negative depends on sensitivity and the pre-test probability the person has COVID-19. Example: someone with abnormal chest x-rays and close COVID-19 positive contacts has a higher risk of false negatives than someone who is asymptomatic.     

Read Tool

#261 – Antivirals for COVID-19

Bottom Line: To date, published RCTs have not demonstrated benefit of treating COVID-19 patients with remdesivir, lopinavir-ritonavir or oseltamivir.  There are signals of potential benefits from one interim analysis of remdesivir and non-statistically different results, but more research is needed. Full publication of studies and ongoing trials will help to answer this question.    

Read Tool

#260 – Are there tools to help assess dyspnea virtually?

Bottom Line: Unfortunately, no specific technique, including the Roth Score, is reliable in assuring dyspneic patients are not at risk and safe to stay home. Furthermore, no studies have evaluated dyspnea assessment in COVID-19 patients. Clinicians are encouraged to use available tools (https://www.bmj.com/content/368/bmj.m1182/infographic) and have patients assessed in-person if there are any concerns. 

Read Tool

#259 – Unmasking the evidence around masks for healthcare workers

Bottom Line: In healthcare workers;

  • Surgical masks and respirators (N95) appear to provide similar protection against viral infections, with N95 masks having slightly lower, but not statistically different, infection rates in the wearer (~1-2%). 
  • Cloth masks are less effective than surgical masks (with ~2% more respiratory infections in 4 weeks).
  • No randomized controlled trials examined transmission from healthcare workers to others and none examined COVID-19.
  • Masks are just one-part of Personal Protective Equipment and transmission precautions.  

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Rheumatology

(6)

#269 – Osteoarthritis pain getting you down? Duloxetine

Bottom Line: Duloxetine can meaningfully reduce osteoarthritis pain scores (by at least 30%) for ~60% of patients compared to ~40% on placebo. An average pain of ~6 (scale 0-10) will be reduced by ~2.5 points, compared to 1.7 on placebo. Duloxetine adverse effects lead to withdrawal in 12% of patients versus 6% on placebo. 

Read Tool

#266 – Exercise-induced osteoarthritis: Running into problems?

Bottom Line: Based on low-quality observational data, running likely does not increase the risk of developing osteoarthritis, except possibly in elite athletes. Additionally, recreational running may be associated with lowering the risk of knee osteoarthritis. Exercise is one of the most effective treatments for reducing osteoarthritic pain.

Read Tool

#262 – Who let the Gout Out? Targeting Uric Acid Levels in Treating Gout

Bottom Line: Best evidence finds that increasing doses of allopurinol to achieve a specific serum urate target (example <360 μmol/L) does not reduce gout flares, pain, or function, compared to standard allopurinol dosing. Febuxostat increases cardiovascular and overall mortality and should not be used in most patients with gout.

Read Tool

#244 – Injecting Evidence into Platelet-Rich Plasma Injections

Bottom Line: The best quality evidence shows no difference in pain, function, or return to sport between platelet-rich plasma, dry needling, or saline for patients with Achilles tendinopathy, lateral epicondylitis, or rotator cuff tendinopathy.

Read Tool

#240 – What is the Incidence of Iatrogenic Opioid Use Disorder?

Bottom Line: The incidence of OUD associated with prescribed opioids among chronic pain patients is likely ~3% (over ~2 years) but causation is uncertain. Patients with no history of substance use disorders appear to be at lower risk (<1%). Factors associated with increased risk of OUD include a history of substance use disorder and receiving opioids for longer duration (>90 days) or at higher doses (>120mg/day morphine equivalent).

Read Tool
  • Page
  • 1
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  • 2

Urology

(3)

#245 – Taking a hard look at the evidence: Phosphodiesterase-5-inhibitors in erectile dysfunction

Bottom Line: PDE5 inhibitors increase the proportion of successful sexual intercourse attempts to ~65% versus ~30% for placebo. For every 3 men given a PDE5 inhibitor compared to placebo, an additional 1 will have “improved erections”.

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#238 – In COPD puffers, does three-of-kind beat a pair?

Bottom Line: In COPD patients with ≥1 exacerbation per year, triple therapy reduces the risk of having ≥1 exacerbations/year compared to LAMA/LABA dual therapy (one less patient for every 36) but increases the risk of pneumonia (one more patient for every 34) and costs. It is possible that higher blood eosinophil counts (>150-300 cells/µL) may help target adding ICS.

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#237 – Verifying the Value of Vaginal Estradiol Tablets

Bottom Line: Vaginal estradiol tablets are likely no better than placebo vaginal gel for reducing “most bothersome symptom scores” (mainly dyspareunia). However, compared to placebo vaginal tablets, they reduce symptoms (example: treatment “success” at 12 months in 86% versus 41% placebo). A non-medicated vaginal gel may be reasonable first-line for dyspareunia.

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