Essential Evidence: Medicine that Matters -- Contents -- Preface -- Taking an Evidence-Based Approach to the Care of Patients -- How to Become an Information Master: Feeling Good about NOT Knowing Everything -- InfoPOEMs (Patient-Oriented Evidence that Matters) -- Cancer -- Breast cancer -- Most women with breast cancer have no risk factors -- Raloxifene reduces breast cancer risk (CORE) -- Raloxifene and tamoxifen equally effective in reducing breast cancer risk -- Raloxifene decreases breast cancer risk, no effect on cardiovascular diseaserisk (RUTH) -- MRI more accurate than mammogram in high-risk patients -- MRI more sensitive than mammography in high-risk women (MARIBS) -- Digital mammography more sensitive for younger women -- Mammography results in overdiagnosis -- Annual mammography starting at 40 doesn't lower breast cancer mortality -- Gynecologic cancers -- Many unnecessary Pap smears are performed after hysterectomy -- Specific HPV strains are associated with cervical cancer risk -- Vaccine effective against HPV -- Bivalent vaccine against HPV effective for 4.5 years -- Liquid-based not better than conventional Pap -- Endometrial sampling adequate for diagnosing endometrial cancer -- Melanoma -- Melanoma incidence really not rising -- Lifetime risk of mole transforming to melanoma very low -- 0.7% of congenital melanocytic nevi become malignant -- Dermoscopy with validated criteria more sensitive than unaided eye -- Larger margins better in melanoma >2mm thick -- Prevention and screening -- Antioxidants don't prevent GI cancers, and may increase overall mortality -- Vitamin E doesn't lower women's risk of cardiovascular disease or cancer -- Antioxidants don't prevent colorectal cancer -- Mammography, FOBT and CXR don't reduce all-cause mortality -- Spiral CT detects early lung cancer, but screening use is premature.

Cancer linked to some diabetes treatments -- Prostate cancer -- Finasteride of mixed benefit in preventing prostate cancer -- Prostate cancer screening every 4 years as good as annually -- False-positive PSA associated with increased worry, fears -- Elevated PSA should be confirmed before biopsy -- Radical prostatectomy improves outcomes in symptom-detected prostate cancer -- Cardiology -- Acute myocardial infarction and acute coronary syndromes -- Early metoprolol in acute MI: no benefit, possible harm (COMMIT -- CCS-2) -- Insulin/dextrose infusion ineffective in AMI (HI-5) -- Early initiation of statins following ACS does not improve outcomes -- Antibiotics not effective in acute coronary syndromes -- ABCDE approach to non-ST-segment elevation ACS -- Door-to-balloon time important in STEMI -- Routine invasive strategy may be preferred for ACS -- Intensive medical tx + selective PCI preferred for non-ST ACS -- Invasive tx slightly better in non-ST-elevation ACS (RITA3) -- In ACS, 5years of invasive tx decreases MI but not all cause mortality (FRISC-II) -- Captopril = losartan for reducing all-cause mortality after Ml -- Captopril better than valsartan or combination post-MI -- Implantable defibrillators are not effective post-MI -- Anticoagulation management -- Start warfarin at 10 mg faster for outpatient anticoagulation -- Use an algorithm to start warfarin in older patients -- Self-monitoring of anticoagulation safe, effective -- Self-monitoring anticoagulation superior at preventing venous thromboembolics events -- INR 1.5-1.9 less effective than 2.0-3.0 for idiopathic DVT -- Oral vitamin K works faster than subcutaneous -- Oral vitamin K effective for warfarin overdose -- Atrial fibrillation -- Clinical decision rules accurately predict stroke risk in atrial fibrillation -- Thromboembolism just as likely with atrial flutter.

Warfarin prevents more strokes than clopidorel + ASA in atrial fibrillation (ACTIVE) -- Ximelagatran effective in preventing stroke in atrial fibrillation -- Quality of life with rate or rhythm control in atrial fibrillation (AFFIRM) -- Rate control better than rhythm control in atrial fibrillation (AFFIRM) -- Amiodarone > sotalol > placebo for maintaining NSR in atrial fibrillation (SAFE-T) -- Coronary artery disease -- Mediterranean diet associated with lower all cause mortality -- Coffee does not increase risk of developing CAD -- Vitamin E has no effect on cardiovascular disease -- Lowering homocysteine does not reduce cardiovascular disease (HOPE 2) -- Omega 3 fatty acids do not affect mortality -- Folie acid supplementation does not reduce cardiovascular disease risk nor mortality -- Fenofibrate doesn't prevent coronary events in DM (FIELD) -- Optimal oral antiplatelet therapy for vascular disease -- Clopidogrel + ASA no better than ASA alone for high-risk patients -- Clopidogrel beneficial added to ASA, fibrinolytic in STEMI -- Aspirin reduces risk of CV events, increases risk of bleeding -- Aspirin + PPI safer than clopidogrel if history of Gl bleed -- Electron beam tomography not helpful -- Chest pain relief by NTG doesn't predict active CAD -- Ranolazine adds little to maximum antianginal therapy (ERICA) -- Better outcomes with CABG than PCI with stent for 2,3 vessel disease -- Adding ACEI doesn't improve outcomes in stable angina w/nl LVEF (PEACE) -- COX-2 inhibitors and heart disease -- Rofecoxib increases risk of cardiovascular events -- Celecoxib increases risk of cardiovascular complications -- Rofecoxib, diclofenac and indomethacin increase risk of CVD -- Heart failure -- BNP improves outcomes in evaluation of dyspnea -- BNP testing beneficial with CHF + pulmonary dx -- Serial BNP levels predict risk of death and CHF after ACS.

Higher BNP and N-ANP predict CV events -- ARBs = ACEIs for all-cause mortality in heart failure -- Optimal digoxin range for men 0.5 to 0.8ng/ml -- Digoxin increases mortality in women with heart failure -- Nesiritide for CHF may increase mortality risk -- Implantable defibrillators reduces mortality in NYHA Class II heart failure -- Hyperlipidemia -- Herbs may reduce cholesterol, no data on clinical outcomes -- Statins prevent CAD -- Cholesterol lowering cost-effective in high-risk elderly -- Intensive lipid lowering of marginal benefit even if high-risk -- Varying effects of lipid drugs on overall mortality -- Statins equivalent for CVD prevention -- Intensive lipid lowering with statins unnecessary with stable CAD (IDEAL) -- Hypertension -- JNC 7 report on prevention/evaluation/treatment of hypertension -- Work stress has no meaningful effect on blood pressure -- Pseudoephedrine has a minimal effect on blood pressure -- Habitual caffeine intake does not increase risk of hypertension in women -- Home blood pressure monitoring valuable -- Office measurements usually overestimate blood pressure -- Hypertension follow-up: 3 months = 6 months -- Patients with HTN + high lipids may benefit less from statins (ALLHAT) -- Excessive lowering of blood pressure causes more harm than good -- Diuretics clearly first line agent for HTN (ALLHAT) -- Meta-analysis supports diuretics as first line for HTN -- Outcomes for thiazides similar -- ACEI better than diuretic in older men for hypertension -- Atenolol of questionable efficacy for HTN -- Beta-blockers > placebo, not other drugs, in preventing HTN complications -- Renal function similarly affected by antihypertensives (ALLHAT) -- Peripheral vascular disease and aneurysm -- Screening program for abdominal aortic aneurysm ineffective -- Fewer aneurysm deaths but not overall deaths with AAA screening.

CABG not helpful before AAA or peripheral vascular surgery -- EVAR worse than open repair of AAA (EVAR Trial 1) -- Bypass = angioplasty for severe leg ischemia, but costs more (BASIL) -- Pulmonary hypertension -- Sildenafil effective for primary pulmonary hypertension -- Sildenafil = bosentan in pulmonary hypertension (SERAPH) -- Thrombophilias -- Testing for prothrombotic defects not necessary after first DVT -- Management of antiphospholipid antibody syndrome -- Venous thromboembolism -- Fixed-dose, subcutaneous, unfractionated heparin effective for VTE -- Compression stockings prevent post-thrombotic syndrome -- Routine use of vena cava filters doesn't reduce mortality -- At least 6 months of anticoagulation optimal to prevent recurrent VTE -- LMWH better than warfarin in preventing recurrent DVT in cancer patients -- Venous thromboembolism diagnosis and prognosis -- Best tests to rule in, rule out PE -- Clinical prediction rules accurate for PE diagnosis -- Validated algorithm for evaluating suspected PE -- Optimal algorithm for evaluating suspected DVT -- Multidetector CT accurate for PE, but requires clinical context -- Negative CT scan to rule out PE equal to angiography -- Determining major bleeding risk with warfarin for DVT -- D-dimer useful for excluding DVT and PE -- D-dimer <250ng/mL predicts low risk of VTE recurrence -- Care of Infants and Children -- ADHD -- Restricted diet improves parental perception of hyperactive behavior -- Stimulants similarly effective for ADHD -- Responders to atomoxetine do well with lower doses -- Anemia -- Anemia not prevented by iron in infants -- Anemia doesn't predict iron deficiency among toddlers -- Asthma -- Long-term budesonide does not effect adrenal function in children -- Amoxicillin for 3 days effective for pediatrie pneumonia -- Educational programs effective for young asthmatics -- Diarrhea.

Nitazoxanide reduces rotavirus duration in hospitalized kids.