Saturday, October 25, 2014 What's New, What's True, and What's Poo? Mike Allan, Mike Kolber ...

115 Pages·2014·17.15 MB·English

by  Sharon Nickel

Saturday, October 25, 2014

What’s New, What’s True, and What’s Poo?
Mike Allan, Mike Kolber,
Tina Korownyk, and Adrienne Lindblad
New, True & Poo: Too
What’s New
What’s True
What’s Poo
Adrienne, Tina, Mike A, Mike K
Evidence & CPD Program, Alberta College of Family Physicians
Department of Family Medicine, University of Alberta
AOM & antibiotics: Wait or not
Diastolic HF: Spironolactone?
• TFP Feb 22, 2011: Abx help AOM 1 in 3- 1 in 10
• TFP Jan 6 2014: Spironolactone=ACE in systolic HF
• DB-RCT 84 kids, (mean age 4.4 yr, 43% male),
• (cid:90)(cid:18)(cid:100)(cid:3)(cid:282)(cid:349)(cid:258)(cid:400)(cid:410)(cid:381)(cid:367)(cid:349)(cid:272)(cid:3)(cid:44)(cid:38)(cid:3)(cid:894)(cid:28)(cid:38)(cid:3)(cid:1096)(cid:1008)(cid:1009)(cid:1081)(cid:895)(cid:853)(cid:3)(cid:1007)(cid:1008)(cid:1008)(cid:1009)(cid:3)pts x 3.3 years
clavulin 40m/kg x 7, focus Middle Ear Effusion.
– Median age 69, female 52%, Class II-III, mean 25mg
• Outcome up to 60days • Outcomes: CV death, survived arrest, hosp for HF
– Resolved effusion: 19d clavulin vs 33d (p=0.02) – 18.6% (spironolactone) vs 20.4%, HR 0.89 (0.77-1.04)
– Normal otoscopy 14d: 45% clavulin vs 19% (NNT 4) – HF Hosp: 12% (spiro) vs 14.2%, NNT 46
– 5 days earache: 0% clavulin vs 17% (NNT 6) – Other outcomes, some or lower but not Stat Sign
– (cid:68)(cid:381)(cid:396)(cid:286)(cid:3)(cid:346)(cid:455)(cid:393)(cid:286)(cid:396)(cid:364)(cid:258)(cid:367)(cid:286)(cid:373)(cid:349)(cid:258)(cid:3)(cid:894)(cid:1096)(cid:1009)(cid:856)(cid:1009)(cid:895)(cid:855)(cid:3)(cid:1005)(cid:1012)(cid:856)(cid:1011)(cid:1081)(cid:3)vs vs 9.1% (NNH 11)
– Mean earache resolved 2.2d clavulin vs 3.2 (p=0.08)
• Verdict: True, New and maybe Poo
• Verdict: True. (Selective) Tx AOM has advantage
JAMA Pediatr. 2014;168(7):635-641. N Engl J Med 2014;370:1383-92.
Glucose lowering sweet again
• TFP Jan 21, 2013: Back off targets in higher risk pts
• RCT, 10,251 higher risk diabetics (A1c of 8.3%)
– Randomized to (cid:1095)6% vs standard: end 6.4% vs 7.5%
– Stopped 3.7 yrs: but then followed +1.3 yrs (5 total)
• Outcomes:
– At 3.7 yrs: non-fatal MI NNT 100 but death NNH 96, 10kg
wgt gain NNH 8, severe hypoglycemia NNH 15
– At 5 years: non-fatal MI NNT 90. other outcomes same
(fatal MI still trending high)
• Let’s look at how these new outcomes differ,…
Gerstein, Lancet. 2014 Jul 31. pii: S0140-6736(14)60611-5. Gerstein, Lancet. 2014 Jul 31. pii: S0140-6736(14)60611-5.
Bugs Need Delayed Drugs? The Pharmaceutical Graveyard
• TFP October 3, 2011: Delayed Abx decrease use
• (cid:90)(cid:18)(cid:100)(cid:3)(cid:1012)(cid:1012)(cid:1013)(cid:3)(cid:393)(cid:396)(cid:349)(cid:373)(cid:258)(cid:396)(cid:455)(cid:3)(cid:272)(cid:258)(cid:396)(cid:286)(cid:3)(cid:894)(cid:258)(cid:336)(cid:286)(cid:3)(cid:1096)3): 4 type of delayed scripts
plus “no” script. Those “needing” Abx got immediately.
• Immediate Abx ued 97% but same Sx scores at day 2-4
Randomized Arm Abx Use Reconsult Very Satisfied Sx score
No Antibiotics 26% 16% 79% 1.62
Recontact (phone) 37% 18% 74% 1.60
Post dated script 37% 10% 80% 1.82
Collect at clinic 33% 14% 88% 1.68
Patient Led 39% 14% 89% 1.75
• Verdict: Still True, Delayed ++ reduces Abx
BMJ 2014;348:g1606 doi: 10.1136/bmj.g1606
Latitude vs Incidence of Colorectal Ca
Darapladib: Something smells funny
• Darapladib: 160mg oral Once a day vs placebo
– Selective inhibitor lipoprotein-associated phospholipase A2.
• DB-RCT: 15,828 patients with previous CHD (age 65,
81% male, 34% DM).
• At 3.7 years,
– CVD death, MI, stroke: No diff, 9.7% (Dara) vs 10.4%
– Mortality: No diff, 7.3% (Dara) vs 7.3%
– Discontinued 32.7% (dara) vs 26.8%, NNH 17
– Odor stool-urine-skin (20% vs 2.2%), + diarrhea (NNH 17)
• Verdict: Poo (really). More Surrogate Sorrow. Conclusion: (cid:207) Distance from equator
= (cid:208) Vitamin D = (cid:207) Colorectal cancer.
N Engl J Med. 2014 May 1;370(18):1702-11.
Vitamin D cure-all: Cancer & CVD
• Systematic Review to examine the effect of
Vitamin d (+/ Calcium), with 9-12 RCTs and
-
almost 50,000 patients in each meta-analysis
– Coronary heart disease: RR 1.02 (0.93-1.13)
– Cerebrovascular disease: RR 1.01 (0.90-1.13)
– Cancer: 0.99 (0.93-1.05)
• They also performed a trial sequential analysis to
determine if more evidence is needed,…
Lancet Diabetes Endocrinol. 2014 Apr;2(4):307-20.
Vitamin D cure-all: Cancer & CVD
How long will this kid be sick for?
• (cid:18)(cid:346)(cid:349)(cid:367)(cid:282)(cid:396)(cid:286)(cid:374)(cid:3)(cid:894)(cid:258)(cid:336)(cid:286)(cid:3)(cid:1095)(cid:1005)(cid:1012)(cid:3)(cid:455)(cid:286)(cid:258)(cid:396)(cid:400)(cid:895)(cid:855)(cid:3)(cid:94)(cid:455)(cid:400)(cid:410)(cid:286)(cid:373)(cid:258)(cid:410)(cid:349)(cid:272)(cid:3)(cid:90)(cid:286)(cid:448)(cid:349)(cid:286)(cid:449)(cid:3)
• 25 cohort studies; 23 RCTs.

Condition # Trials (#pt) Days to Symptoms resolved for
# Cohort (#pt)
50% children 90% children
Earache 7 (958 kids) 3 7-8
3 (451 kids)
Strep throat 6 (241 kids) Mean 2-7 days to complete resolution
/Tonsillitis 1 (103 infants) ((cid:1195)(cid:1067)(cid:3)(cid:400)(cid:410)(cid:349)(cid:367)(cid:367)(cid:3)Sx day 3)
Non-specific RTI 4 (457 kids) 7-8 16
15 (4870 kids)
Common Cold 10 15
Acute Cough 6 (700 kids) 10 25
6 (1063 kids)
• Verdict: Poo (Theory Vitamin D effects all health) Bronchiolitis 13 21
Lancet Diabetes Endocrinol. 2014 Apr;2(4):307-20. BMJ 2013;347:f7027 doi: 10.1136/bmj.f7027
In Alopecia, Potent is Impotant
Impingement: Shot in the arm vs PT
• DB-RCT 42 (mean age 7.4 yrs, 44% male, >10%
• RCT (unblinded): 104 pts (mean 41 yr, 68% male)
scalp hair loss), Cycles of clobetasol 0.05% or
– Referred to PT from ortho or GP (military hospital)
hydrocortisone 1% BID x6wks, off 6xwks, repeat.
– 1-3 subacromial shots (40mg triamcinolone) vs twice
– Super high potency (1) vs lowest (7), betameth Val =3
weekly PT for 3 weeks.
• Outcome at 24 weeks,
• Outcomes: at 1 month, both 1.6-2.2 VAS better
– Mean percent improvement: 97% clob vs 5% (p=002)
– >50% alopecia reduction: 85% clob vs 33% (NNT 2) – At 1, 3, 6, 12 months x3 pain/disability score: No diff
– One clobetasol patient experienced skin atrophy that – (cid:94)(cid:410)(cid:286)(cid:396)(cid:381)(cid:349)(cid:282)(cid:855)(cid:3)(cid:1096)(cid:1005)(cid:3)(cid:38)(cid:87)(cid:3)(cid:448)(cid:349)(cid:400)(cid:349)(cid:410)(cid:400)(cid:3)(cid:1010)(cid:1004)(cid:1081)(cid:3)(cid:894)vs 37%), NNH 5
resolved spontaneously in 6 weeks.
• Verdict: New. Little diff between interventions
• Verdict: New. Use high potency for alopecia
JAMA Dermatol. 2014 Jan;150(1):47-50. Ann Intern Med. 2014;161:161-169.
Acetaminophen in Pregnancy & ADHD
Warfarin + Abx = Careful
• Acetaminophen in 64,322 pregnancy (cid:207) risk of
• Cohort: 22,722 warfarin pts (19% valves)
– More behavioral problems on a Strengths &
– Mean 70 yrs, 97% male (veterans)
Difficulties Questionnaire at 7 years: RR 1.13 (1.01-
1.27) – High & low risk Abx (e.g clinda & keflex low)
– From a government central registry (over ~11 years) • Outcome: Admission bleed (57% GI, 25% GU)
• Diagnosis of hyperkinetic disorder: HR 1.37 (1.19-1.59) – High risk Abx 0.66% & Low risk Abx 0.44%: HR 1.48 ss
• (cid:87)(cid:396)(cid:286)(cid:400)(cid:272)(cid:396)(cid:349)(cid:393)(cid:410)(cid:349)(cid:381)(cid:374)(cid:3)(cid:381)(cid:296)(cid:3)(cid:1096)(cid:1006)(cid:3)(cid:4)(cid:24)(cid:44)(cid:24)(cid:3)(cid:373)(cid:286)(cid:282)(cid:349)(cid:272)(cid:258)(cid:410)(cid:349)(cid:381)(cid:374)(cid:400)(cid:855)(cid:3)HR 1.29 (1.15-1.44)
– Higher risk if malignancy, valves, renal failure: ~2x
– Generally, worse with more wks of use and (although
– Lower risk if check INR sooner (3-14 days): HR 0.61 ss
less consistent) later in pregnancy.
• Verdict: True, Go careful with Abx on warfarin.
• Another (Norwegian) study found similar
– Give Abx if needed, but checking INR may be wise
• (cid:115)(cid:286)(cid:396)(cid:282)(cid:349)(cid:272)(cid:410)(cid:855)(cid:3)(cid:69)(cid:286)(cid:449)(cid:3)(cid:894)(cid:845)(cid:100)(cid:396)(cid:437)(cid:286)(cid:895)(cid:856)(cid:3)(cid:3)(cid:3)(cid:28)(cid:400)(cid:410)(cid:349)(cid:373)(cid:258)(cid:410)(cid:286)(cid:282)(cid:3)(cid:69)(cid:69)(cid:44)(cid:1091)(cid:3)51-146.
Am J Med. 2014 Jul;127(7):657-663.
JAMA Pediatr. 2014;168:313-20. Int J Epidemiol. 2013;42:1702-13.
RESEARCH
• New Knowledge:
– If you are forced to eat, your intake will increase.
– This might lead to weight gain
OBESITY Vol. 15 No. 3 March 2007 673
Investigated the horrors of,…
Will giving Q10 increase your Q10 levels?
Reusable Shopping Bags
• New Knowledge
Gerba CP, Williams D, Sinclair RG (2010). Assessment of the potential for cross contamination of food products by reusable
– If you give anything shopping bags.
• New Knowledge,
that the body absorbs
– If you pour meat juice in bags &leave them
(like Q10), you can
in hot place (trunk), bacteria can grow.
find higher levels in
the serum
. BioFactors 9 (1999) 315–318. J Hypertens 2007; 27:1863 – 1872
Can Evidence Be Complementary to
Alternative Medicine?
Tony Nickonchuk
Can Evidence Be Complementary to Written & Presented By
Alternative Medicine?
Tony Nickonchuk, BSc. Pharm.
Hospital Pharmacist, Alberta Health Services
Peace River
Presenter Disclosure Disclosure of Commercial Support
(cid:121)Presenter: Tony Nickonchuk (cid:121)This program has received NO
COMMERCIAL financial
(cid:121)Relationships that may introduce support
potential bias and/or conflict of
(cid:121)This program has received NO
interest:
COMMERCIAL in-kind support
(cid:121)No relationship to declare
“Alternative” Medicine Why Should We Care?
“a set of practices which cannot be tested, refuse to be tested, or
consistently fail tests. If a healing technique is demonstrated to have
“He’s the best physician that knows the worthlessness of the most
curative properties in properly controlled double-blind trials, it
medicines.”
ceases to be alternative [and] simply becomes medicine. There is no
-Benjamin Franklin
alternative medicine. There is only medicine that works and
medicine that doesn’t.”
-Richard Dawkins
Patients Use It More Than We Think We Don’t Always Know
(cid:121) Estimates of any CAM use as high as 70%1, while 12%2 (cid:121) Consistently shown that female gender, higher education, and
report visiting a CAM practitioner in the last year higher income linked with CAM usage1
(cid:121) Natural health products account for roughly 11% of all OTC (cid:121) Study done at Stollery and CHEO found 60% of pediatric
purchases in Canada3 oncology patients were using at least one form of CAM and
were not discussing it with physician2
(cid:121) Over 5 million Canadians report using some form of CAM in
the last year4 (cid:121) Estimates that up to 70% of patients do not inform MD3, and
we miss it too, documenting CAM use in medical record only
30% of the time4
1. Can J Clin Pharmacol 2008;15(1):e5-e14 1. Ochsner J 2012;12(1):45-56
2. BMC Comp Alt Med 2010;10:58 doi:10.1186/1472-6882-10-58 2. Evid Based Comp Alt Med 2013;2013:527163 doi: 10.1155/2013/527163 Epub 2013 Nov 6
3. 2013 OTC Market Report. http://goo.gl/Rlm2Gy. Accessed September 27, 2014 3. CFP 2008;54(8):1142-4
4. CAM in Practice and Policy. http://goo.gl/KROfBT. Accessed September 27, 2014 4. Br J Clin Pharmacol 2005 Feb;59(2):254-8