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 #300 – No Gain, No Pain? – What is the effect of diet-induced weight loss on osteoarthritis-related knee pain?

Will diet-induced weight loss reduce osteoarthritic knee pain in overweight and obese adults?

BOTTOM LINE:  Observational data suggests that obesity may be a risk factor for developing osteoarthritis, however trials reporting diet-induced weight loss alone (example 5% weight loss) demonstrate limited, likely clinically insignificant improvements in osteoarthritic pain (~5 points on 100-point pain scale) compared to control. Studies are limited by the small magnitude of weight loss. Read More

Tools for Practice #299 – Cardiovascular prevention trials: Now calling colchicine to the stand

Is colchicine effective for secondary cardiovascular prevention?

BOTTOM LINE: Daily low-dose colchicine in people with coronary artery disease (CAD) lowers the risk of cardiovascular events by ~1%/year (relative risk reduction 25-30%), but increases the risk of gastrointestinal events (mostly diarrhea) by ~2% and has no effect on mortality. Read More

Tools for Practice #298 – Long COVID: A (somewhat) short summary of risks, symptoms, and natural course

How common is Long COVID, what are the symptoms and how long does it last?

BOTTOM LINE:  The presence of Long Covid (persistence of ≥1 symptom after acute infection) is found in 20-80% at 60 days post-infection, varying widely based on study design and population. Risk factors include increased age, increased severity of initial infection and female sex. Fatigue, dyspnea, and cognitive effects are the most common symptoms, but the list is long. Symptoms decline over time, but some patients will have persistent symptoms at and possibly beyond 8 months. Read More

Tools for Practice #297 – Opening a can of helminths: Ivermectin for COVID-19

Does ivermectin improve clinical outcomes in COVID-19?

BOTTOM LINE: The best available evidence does not show that ivermectin improves clinically important outcomes in COVID-19. Use in COVID-19 is discouraged. Read More

Tools for Practice #296 – Frequent migraines are a headache: Can biologics help?

What is the efficacy of Calcitonin Gene Related Peptide (CGRP) inhibitors in migraine prophylaxis?

BOTTOM LINE: For patients with episodic and chronic migraines, treating 5-8 patients with a CGRP-inhibitor will lead to one patient experiencing at least a 50% reduction in monthly migraine days compared to placebo. From baseline, a decrease of 1-2 monthly migraine days may be seen. Cost may limit use. 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?

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#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

(15)

#291 – Early dual antiplatelet therapy after minor stroke: Does it take two to tango?

BOTTOM LINE: Compared to ASA alone, clopidogrel plus ASA reduced the risk of stroke from 8.2% to 5.5% but increased the risk of major bleeds from 0.6% to 1.2% at 21 days. Continuing clopidogrel beyond 21 days increased major bleeds without reducing strokes. There is no evidence that ticagrelor is more efficacious in reducing stroke than clopidogrel.

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#289 – Keeping it Simple for Emergency Room Dyspepsia

BOTTOM LINE: Best evidence suggests adding lidocaine and/or anti-spasmodics to antacids is unlikely to add meaningful pain relief compared to antacids alone. Evidence is inconsistent with one study finding antacids alone better, another no added benefit and a third (unblinded, older) showing lidocaine provided additional benefit. Patients (especially females) who present to emergency with new onset dyspepsia should have cardiac diagnosis ruled out.

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#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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Chronic Pain

(8)

#290 – Needle in a Pain-Stack: Acupuncture for Chronic Low Back Pain

BOTTOM LINE: The benefit of acupuncture for chronic low back pain is unclear. At best, one in 6 patients will get meaningful pain relief (>=30% reduction in pain) over control. The benefit is reduced to one in 20 when compared to sham acupuncture and disappears when studies of higher quality or longer duration are considered.

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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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Dermatology

(6)

#288 – Clearing up the evidence for topical acne combination products

BOTTOM LINE: For patients using combination products, including benzoyl peroxide/adapalene and benzoyl peroxide/clindamycin, about 40- 50% will perceive complete or near complete improvement in their acne, compared to 30-40% using individual products, and 20-30% using vehicle. No direct head-to-head trials with patient reported outcomes exist between combination products. Cost may influence product choice.

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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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#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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Emergency

(17)

#291 – Early dual antiplatelet therapy after minor stroke: Does it take two to tango?

BOTTOM LINE: Compared to ASA alone, clopidogrel plus ASA reduced the risk of stroke from 8.2% to 5.5% but increased the risk of major bleeds from 0.6% to 1.2% at 21 days. Continuing clopidogrel beyond 21 days increased major bleeds without reducing strokes. There is no evidence that ticagrelor is more efficacious in reducing stroke than clopidogrel.

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#289 – Keeping it Simple for Emergency Room Dyspepsia

BOTTOM LINE: Best evidence suggests adding lidocaine and/or anti-spasmodics to antacids is unlikely to add meaningful pain relief compared to antacids alone. Evidence is inconsistent with one study finding antacids alone better, another no added benefit and a third (unblinded, older) showing lidocaine provided additional benefit. Patients (especially females) who present to emergency with new onset dyspepsia should have cardiac diagnosis ruled out.

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.

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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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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

(4)

#289 – Keeping it Simple for Emergency Room Dyspepsia

BOTTOM LINE: Best evidence suggests adding lidocaine and/or anti-spasmodics to antacids is unlikely to add meaningful pain relief compared to antacids alone. Evidence is inconsistent with one study finding antacids alone better, another no added benefit and a third (unblinded, older) showing lidocaine provided additional benefit. Patients (especially females) who present to emergency with new onset dyspepsia should have cardiac diagnosis ruled out.

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#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

(48)

#291 – Early dual antiplatelet therapy after minor stroke: Does it take two to tango?

BOTTOM LINE: Compared to ASA alone, clopidogrel plus ASA reduced the risk of stroke from 8.2% to 5.5% but increased the risk of major bleeds from 0.6% to 1.2% at 21 days. Continuing clopidogrel beyond 21 days increased major bleeds without reducing strokes. There is no evidence that ticagrelor is more efficacious in reducing stroke than clopidogrel.

Read Tool

#290 – Needle in a Pain-Stack: Acupuncture for Chronic Low Back Pain

BOTTOM LINE: The benefit of acupuncture for chronic low back pain is unclear. At best, one in 6 patients will get meaningful pain relief (>=30% reduction in pain) over control. The benefit is reduced to one in 20 when compared to sham acupuncture and disappears when studies of higher quality or longer duration are considered.

Read Tool

#289 – Keeping it Simple for Emergency Room Dyspepsia

BOTTOM LINE: Best evidence suggests adding lidocaine and/or anti-spasmodics to antacids is unlikely to add meaningful pain relief compared to antacids alone. Evidence is inconsistent with one study finding antacids alone better, another no added benefit and a third (unblinded, older) showing lidocaine provided additional benefit. Patients (especially females) who present to emergency with new onset dyspepsia should have cardiac diagnosis ruled out.

Read Tool

#288 – Clearing up the evidence for topical acne combination products

BOTTOM LINE: For patients using combination products, including benzoyl peroxide/adapalene and benzoyl peroxide/clindamycin, about 40- 50% will perceive complete or near complete improvement in their acne, compared to 30-40% using individual products, and 20-30% using vehicle. No direct head-to-head trials with patient reported outcomes exist between combination products. Cost may influence product choice.

Read Tool

#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.

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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).

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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.

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#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.

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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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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.

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#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.

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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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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.

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#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.

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#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

(3)

#291 – Early dual antiplatelet therapy after minor stroke: Does it take two to tango?

BOTTOM LINE: Compared to ASA alone, clopidogrel plus ASA reduced the risk of stroke from 8.2% to 5.5% but increased the risk of major bleeds from 0.6% to 1.2% at 21 days. Continuing clopidogrel beyond 21 days increased major bleeds without reducing strokes. There is no evidence that ticagrelor is more efficacious in reducing stroke than clopidogrel.

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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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).

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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.

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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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#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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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

(9)

#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

(4)

#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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