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 #287 – How to Slow the Flow: NSAIDs for Heavy Menstrual Bleeding

In premenopausal heavy menstrual bleeding without pathological cause, do nonsteroidal anti-inflammatory drugs (NSAIDs) improve patient outcomes?

Bottom Line: Based on low-quality evidence, NSAIDs reduce relative mean menstrual blood loss by ~30%, and ~20-50% fewer sanitary products used than placebo. Effects on bleeding duration are inconsistent. Read More

Tools for Practice #286 – Vaccine hesitancy in the office: What can I do?

What office-based interventions in primary care help reduce vaccine hesitancy?

Bottom Line: Clinicians should explicitly recommend vaccination and focus discussion on the disease-prevention benefits to the individual more than correcting misinformation or on benefits to society. Interventions are more likely to be effective in those with neutral attitudes towards vaccination than those opposed. Read More

Tools for Practice #285 – Should a ‘flozin be chosen to play a part for a failing heart?

What is the role of sodium-glucose cotransporter 2 inhibitors (SGLT2i) in patients with chronic heart failure with reduced ejection fraction?

Bottom Line: SGLT2i reduce mortality, heart failure hospitalizations, and improve quality of life when added to other medications in patients with heart failure with reduced ejection fraction, with or without diabetes. For every 100 patients treated with an SGLT2i for ~1.5 years, ~2 fewer will die, ~4 fewer will be hospitalized for heart failure, and ~7 will have improved quality of life (at 8 months) compared to placebo. Read More

Tools for Practice #282 – Osteoporosis treatment for post-menopausal women

How effective are bisphosphonates and denosumab in preventing fractures in post-menopausal women?

Bottom Line: Bisphosphonates and denosumab are similarly effective at reducing risk of fracture in post-menopausal women. Over 1-4 years, bisphosphonates or denosumab provide an absolute reduction of ~0.5-1.0% for hip fractures, ~1.5-3% for non-vertebral fractures and ~3-6% for vertebral fractures compared to placebo. Read More

Tools for Practice #284 – Iron dosing frequency: Is less more or just less?

How does once daily iron dosing compare with dosing every second day or twice weekly?

Bottom Line: Once daily dosing of iron yields similar or slightly better hemoglobin (~3 g/L) versus twice weekly or alternate day over ~3 months. Daily dosing increased ferritin similarly or up to 12 mg/L better. Adverse events (like abdominal pain) are reduced by up to 30% (absolute) with intermittent dosing. Research focused on females aged 14-22. Read More

Dr. Mike Kolber's PEER Picks

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

How do biosimilar medications compare to their corresponding originator biologic medications in treating patients with conditions like rheumatoid arthritis or inflammatory bowel disease?

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#195 – Shooting the Breeze on Supervised Injection Sites

Do supervised injection sites (SIS) reduce mortality, hospitalizations, ambulance calls, or disease transmission?

Read More

#61 – Is Hydrochlorothiazide the Best Thiazide Diuretic for Hypertension?

When choosing a thiazide diuretic for hypertension, is hydrochlorothiazide (HCTZ) the best choice?

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Tools for Practice by Catagory

Allergy-Immunology

(1)

#280- COVID Vax Fast Facts: Say That 10 Times Fast

Interim results of two large randomized, placebocontrolled trials (RCTs) demonstrate ~95% relative efficacy in preventing COVID-19 (Pfizer, Moderna). The AstraZeneca/Oxford vaccine has ~70% relative efficacy. Absolute benefits will vary with baseline risk and time but if annual risk of developing COVID-19 is 20%, then vaccine would decrease risk to 1% (6% with AstraZeneca/Oxford). These vaccines appear safe and may decrease the likelihood of severe COVID-19. Ongoing studies should provide further details.

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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.

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#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).

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#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).

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Cardiology

(13)

#285 – Should a ‘flozin be chosen to play a part for a failing heart?

Bottom Line: SGLT2i reduce mortality, heart failure hospitalizations, and improve quality of life when added to other medications in patients with heart failure with reduced ejection fraction, with or without diabetes. For every 100 patients treated with an SGLT2i for ~1.5 years, ~2 fewer will die, ~4 fewer will be hospitalized for heart failure, and ~7 will have improved quality of life (at 8 months) compared to placebo.

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#281 – Hindsight: Top 5 Tools for Practice of 2020

Hindsight: Top 5 Tools for Practice of 2020

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#279- What’s under the Mistletoe? Some fun holiday evidence from PEER

Bottom Line: Kissing freely for 30 minutes while listening to soft music may improve surrogate markers of atopy (like wheal reactions on allergy test). Another small RCT found that advice to increase kissing improved relationship satisfaction and even slightly reduced (0.15mmol/L) total cholesterol. We did not identify studies of mistletoe. Further research is required.

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#277 – Somethin’ Fishy: Prescription variants of Omega-3 to prevent cardiovascular disease

Bottom Line: In high risk patients, icosapent reduced cardiovascular events to 17% from 22% on placebo after 5 years. In lower risk patients, Eicosapentaenoic Acid (EPA) ethyl ester reduced major cardiovascular events to 2.8% from 3.5% with control after 5 years. Whether these products differ from each other or traditional omega-3 fatty acids (that don’t show cardiovascular benefit) is unknown. Cost will likely limit use.

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#271 – Be still my quivering heart: alcohol and atrial fibrillation

Bottom Line: Observational studies consistently report a doseresponse association between alcohol and new onset atrial fibrillation. Based on 1 randomized controlled trial (RCT) of “regular drinkers” with paroxysmal atrial fibrillation, recurrence of atrial fibrillation happened in ~50% who abstain compared to ~70% who continue drinking. Abstaining can prevent 1 atrial fibrillation-related hospital visit for every 9 people compared to those who continue to drink at 6 months.

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Chronic Pain

(7)

#281 – Hindsight: Top 5 Tools for Practice of 2020

Hindsight: Top 5 Tools for Practice of 2020

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#276 – Glucosamine & Chondroitin: Natural remedies for osteoarthritis?

Bottom Line: Glucosamine and chondroitin do not appear to be effective in higher-quality, larger and/or publicly funded studies. If studies at high risk of bias are included, at best ~10% more people will have meaningful reduction in pain with either treatment over 35-45% of people with placebo. There is reason to doubt the effectiveness of either treatments.

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#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. 

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#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.

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#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
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Dermatology

(5)

#279- What’s under the Mistletoe? Some fun holiday evidence from PEER

Bottom Line: Kissing freely for 30 minutes while listening to soft music may improve surrogate markers of atopy (like wheal reactions on allergy test). Another small RCT found that advice to increase kissing improved relationship satisfaction and even slightly reduced (0.15mmol/L) total cholesterol. We did not identify studies of mistletoe. Further research is required.

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#272 – Putting the FUN in fungi (Part 2): Topical management of tinea pedis

Bottom Line: Tinea pedis is successfully treated with topical antifungals in 70-75% of patients compared to 20-30% using placebo. Tea tree oil is likely ineffective. Topical terbinafine may result in an absolute improvement of 2-8% more patients cured over other topicals. The majority of patients were treated for 1 week with terbinafine and 4-6 weeks with azoles (like clotrimazole).

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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.

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#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.

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#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

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Emergency

(15)

#281 – Hindsight: Top 5 Tools for Practice of 2020

Hindsight: Top 5 Tools for Practice of 2020

Read Tool

#280- COVID Vax Fast Facts: Say That 10 Times Fast

Interim results of two large randomized, placebocontrolled trials (RCTs) demonstrate ~95% relative efficacy in preventing COVID-19 (Pfizer, Moderna). The AstraZeneca/Oxford vaccine has ~70% relative efficacy. Absolute benefits will vary with baseline risk and time but if annual risk of developing COVID-19 is 20%, then vaccine would decrease risk to 1% (6% with AstraZeneca/Oxford). These vaccines appear safe and may decrease the likelihood of severe COVID-19. Ongoing studies should provide further details.

Read Tool

#271 – Be still my quivering heart: alcohol and atrial fibrillation

Bottom Line: Observational studies consistently report a doseresponse association between alcohol and new onset atrial fibrillation. Based on 1 randomized controlled trial (RCT) of “regular drinkers” with paroxysmal atrial fibrillation, recurrence of atrial fibrillation happened in ~50% who abstain compared to ~70% who continue drinking. Abstaining can prevent 1 atrial fibrillation-related hospital visit for every 9 people compared to those who continue to drink at 6 months.

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#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.   

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#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.

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Endocrinology

(6)

#285 – Should a ‘flozin be chosen to play a part for a failing heart?

Bottom Line: SGLT2i reduce mortality, heart failure hospitalizations, and improve quality of life when added to other medications in patients with heart failure with reduced ejection fraction, with or without diabetes. For every 100 patients treated with an SGLT2i for ~1.5 years, ~2 fewer will die, ~4 fewer will be hospitalized for heart failure, and ~7 will have improved quality of life (at 8 months) compared to placebo.

Read Tool

#281 – Hindsight: Top 5 Tools for Practice of 2020

Hindsight: Top 5 Tools for Practice of 2020

Read Tool

#279- What’s under the Mistletoe? Some fun holiday evidence from PEER

Bottom Line: Kissing freely for 30 minutes while listening to soft music may improve surrogate markers of atopy (like wheal reactions on allergy test). Another small RCT found that advice to increase kissing improved relationship satisfaction and even slightly reduced (0.15mmol/L) total cholesterol. We did not identify studies of mistletoe. Further research is required.

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%.

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#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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ENT

(1)

#281 – Hindsight: Top 5 Tools for Practice of 2020

Hindsight: Top 5 Tools for Practice of 2020

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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.

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#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%.

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#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

(44)

#287 – How to Slow the Flow: NSAIDs for Heavy Menstrual Bleeding

Bottom Line: Based on low-quality evidence, NSAIDs reduce relative mean menstrual blood loss by ~30%, and ~20-50% fewer sanitary products used than placebo. Effects on bleeding duration are inconsistent.

Read Tool

#286 – Vaccine hesitancy in the office: What can I do?

Bottom Line: Clinicians should explicitly recommend vaccination and focus discussion on the disease-prevention benefits to the individual more than correcting misinformation or on benefits to society. Interventions are more likely to be effective in those with neutral attitudes towards vaccination than those opposed.

Read Tool

#285 – Should a ‘flozin be chosen to play a part for a failing heart?

Bottom Line: SGLT2i reduce mortality, heart failure hospitalizations, and improve quality of life when added to other medications in patients with heart failure with reduced ejection fraction, with or without diabetes. For every 100 patients treated with an SGLT2i for ~1.5 years, ~2 fewer will die, ~4 fewer will be hospitalized for heart failure, and ~7 will have improved quality of life (at 8 months) compared to placebo.

Read Tool

#282 – Osteoporosis treatment for post-menopausal women

Bottom Line: Bisphosphonates and denosumab are similarly effective at reducing risk of fracture in post-menopausal women. Over 1-4 years, bisphosphonates or denosumab provide an absolute reduction of ~0.5-1.0% for hip fractures, ~1.5-3% for non-vertebral fractures and ~3-6% for vertebral fractures compared to placebo.

Read Tool

#284 – Iron dosing frequency: Is less more or just less?

Bottom Line: Once daily dosing of iron yields similar or slightly better hemoglobin (~3 g/L) versus twice weekly or alternate day over ~3 months. Daily dosing increased ferritin similarly or up to 12 mg/L better. Adverse events (like abdominal pain) are reduced by up to 30% (absolute) with intermittent dosing. Research focused on females aged 14-22.

Read Tool
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General Surgery

(3)

#273 – Virtual visits versus face-to-face: Diagnostic accuracy in primary care

Bottom Line: Based on limited, lower-level evidence, diagnostic accuracy of virtual visits was between 71-91%, measured using standardized patients or case review at 3 months. Diagnostic accuracy/agreement of virtual care seems similar to in-person visits. These studies do not address continuity of care or patient outcomes.

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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

#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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Geriatrics

(3)

#282 – Osteoporosis treatment for post-menopausal women

Bottom Line: Bisphosphonates and denosumab are similarly effective at reducing risk of fracture in post-menopausal women. Over 1-4 years, bisphosphonates or denosumab provide an absolute reduction of ~0.5-1.0% for hip fractures, ~1.5-3% for non-vertebral fractures and ~3-6% for vertebral fractures compared to placebo.

Read Tool

#275 – A good sleep would be dop(aminergic) doc! Pramipexole in restless legs syndrome

Bottom Line: Systematic review of twelve randomized controlled trials demonstrates 63% of patients using pramipexole report feeling much or very much better compared to 41% on placebo over 3-26 weeks. Lower doses (example 0.25/0.5mg) may have equivalent efficacy to higher doses with less risk of augmentation (paradoxical worsening of symptoms with treatment), although up to ~40% of patients may experience augmentation after 1 year.

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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Hematology

(4)

#287 – How to Slow the Flow: NSAIDs for Heavy Menstrual Bleeding

Bottom Line: Based on low-quality evidence, NSAIDs reduce relative mean menstrual blood loss by ~30%, and ~20-50% fewer sanitary products used than placebo. Effects on bleeding duration are inconsistent.

Read Tool

#284 – Iron dosing frequency: Is less more or just less?

Bottom Line: Once daily dosing of iron yields similar or slightly better hemoglobin (~3 g/L) versus twice weekly or alternate day over ~3 months. Daily dosing increased ferritin similarly or up to 12 mg/L better. Adverse events (like abdominal pain) are reduced by up to 30% (absolute) with intermittent dosing. Research focused on females aged 14-22.

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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Infectious Disease

(16)

#286 – Vaccine hesitancy in the office: What can I do?

Bottom Line: Clinicians should explicitly recommend vaccination and focus discussion on the disease-prevention benefits to the individual more than correcting misinformation or on benefits to society. Interventions are more likely to be effective in those with neutral attitudes towards vaccination than those opposed.

Read Tool

#283 – COVID-19 and Vitamin D: Partners in Crime, or Simply Associates?

Bottom Line: While observational evidence suggests an association between low vitamin D levels and COVID-19 infection, it is unclear if this is simply reflective of overall health status. There are no randomized, controlled trials (RCTs) assessing vitamin D for prevention of COVID-19 infections. The highest quality RCT of vitamin D treatment during hospitalization did not demonstrate benefit for clinical outcomes.

Read Tool

#281 – Hindsight: Top 5 Tools for Practice of 2020

Hindsight: Top 5 Tools for Practice of 2020

Read Tool

#280- COVID Vax Fast Facts: Say That 10 Times Fast

Interim results of two large randomized, placebocontrolled trials (RCTs) demonstrate ~95% relative efficacy in preventing COVID-19 (Pfizer, Moderna). The AstraZeneca/Oxford vaccine has ~70% relative efficacy. Absolute benefits will vary with baseline risk and time but if annual risk of developing COVID-19 is 20%, then vaccine would decrease risk to 1% (6% with AstraZeneca/Oxford). These vaccines appear safe and may decrease the likelihood of severe COVID-19. Ongoing studies should provide further details.

Read Tool

#272 – Putting the FUN in fungi (Part 2): Topical management of tinea pedis

Bottom Line: Tinea pedis is successfully treated with topical antifungals in 70-75% of patients compared to 20-30% using placebo. Tea tree oil is likely ineffective. Topical terbinafine may result in an absolute improvement of 2-8% more patients cured over other topicals. The majority of patients were treated for 1 week with terbinafine and 4-6 weeks with azoles (like clotrimazole).

Read Tool
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Nephrology

(1)

#281 – Hindsight: Top 5 Tools for Practice of 2020

Hindsight: Top 5 Tools for Practice of 2020

Read Tool
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Neurology

(2)

#275 – A good sleep would be dop(aminergic) doc! Pramipexole in restless legs syndrome

Bottom Line: Systematic review of twelve randomized controlled trials demonstrates 63% of patients using pramipexole report feeling much or very much better compared to 41% on placebo over 3-26 weeks. Lower doses (example 0.25/0.5mg) may have equivalent efficacy to higher doses with less risk of augmentation (paradoxical worsening of symptoms with treatment), although up to ~40% of patients may experience augmentation after 1 year.

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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Obstetrics-Gynecology

(3)

#287 – How to Slow the Flow: NSAIDs for Heavy Menstrual Bleeding

Bottom Line: Based on low-quality evidence, NSAIDs reduce relative mean menstrual blood loss by ~30%, and ~20-50% fewer sanitary products used than placebo. Effects on bleeding duration are inconsistent.

Read Tool

#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
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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
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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.

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#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.

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Psychiatry

(5)

#279- What’s under the Mistletoe? Some fun holiday evidence from PEER

Bottom Line: Kissing freely for 30 minutes while listening to soft music may improve surrogate markers of atopy (like wheal reactions on allergy test). Another small RCT found that advice to increase kissing improved relationship satisfaction and even slightly reduced (0.15mmol/L) total cholesterol. We did not identify studies of mistletoe. Further research is required.

Read Tool

#278 – Gabapentin for Alcohol Use Disorder: Decrease pints with a pill?

Bottom Line: More patients on gabapentin (27%) could avoid heavy drinking days (example >5 standard drinks/day) compared to those on placebo (9%). There is mixed evidence for gabapentin and abstinence. Gabapentin may be considered as a second-line option (off-label) for AUD (after acamprosate or naltrexone). Concerns regarding abuse/misuse and drug related harms should inform therapeutic discussion.

Read Tool

#271 – Be still my quivering heart: alcohol and atrial fibrillation

Bottom Line: Observational studies consistently report a doseresponse association between alcohol and new onset atrial fibrillation. Based on 1 randomized controlled trial (RCT) of “regular drinkers” with paroxysmal atrial fibrillation, recurrence of atrial fibrillation happened in ~50% who abstain compared to ~70% who continue drinking. Abstaining can prevent 1 atrial fibrillation-related hospital visit for every 9 people compared to those who continue to drink at 6 months.

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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Pulmonology

(8)

#281 – Hindsight: Top 5 Tools for Practice of 2020

Hindsight: Top 5 Tools for Practice of 2020

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#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.

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#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.     

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#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.    

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#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. 

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Rheumatology

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#282 – Osteoporosis treatment for post-menopausal women

Bottom Line: Bisphosphonates and denosumab are similarly effective at reducing risk of fracture in post-menopausal women. Over 1-4 years, bisphosphonates or denosumab provide an absolute reduction of ~0.5-1.0% for hip fractures, ~1.5-3% for non-vertebral fractures and ~3-6% for vertebral fractures compared to placebo.

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#281 – Hindsight: Top 5 Tools for Practice of 2020

Hindsight: Top 5 Tools for Practice of 2020

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#276 – Glucosamine & Chondroitin: Natural remedies for osteoarthritis?

Bottom Line: Glucosamine and chondroitin do not appear to be effective in higher-quality, larger and/or publicly funded studies. If studies at high risk of bias are included, at best ~10% more people will have meaningful reduction in pain with either treatment over 35-45% of people with placebo. There is reason to doubt the effectiveness of either treatments.

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#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. 

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#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.

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Urology

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#270 – Burning Evidence for Fosfomycin in Cystitis

Bottom Line: At best, single dose fosfomycin has similar efficacy to other antibiotics for uncomplicated cystitis. However, the best quality, publicly funded trial showed it was not as efficacious as nitrofurantoin, with 58% of cases clinically resolving at 28 days compared to 70% for nitrofurantoin.

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#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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