Which imaging modality is best for suspected stroke?

Patients exhibiting stroke symptoms should have brain imaging immediately within 3 hours of symptom onset (strength of recommendation [SOR]: A, based on systematic review). In the first 3 hours after a suspected cerebrovascular accident (CVA), noncontrast head computerized tomography (CT) is the gold standard for diagnosis of acute hemorrhagic stroke (SOR: C, based on expert panel consensus). However, the sensitivity for hemorrhage declines steeply 8 to 10 days after the event. Eligibility guidelines for acute thrombolytic therapy are currently based on use of CT to rule out acute hemorrhagic stroke. Magnetic resonance imaging (MRI) may be equally accurate in diagnosing an acute hemorrhagic stroke if completed within 90 minutes of presentation for patients whose symptoms began fewer than 6 hours earlier (SOR: B, based on a single high-quality cohort study). MRI is more sensitive than CT for ischemic stroke in the first 24 hours of symptoms (SOR: B, based on systematic review of low-quality studies with consistent findings) and is more sensitive than CT in the diagnosis of hemorrhagic or ischemic stroke greater than 1 week after symptom onset (SOR: B, based on 1 high-quality prospective cohort study)

Which vaccinations are indicated after splenectomy?

Immunization against encapsulated bacterial pathogens decreases the incidence of post- splenectomy sepsis. Pneumococcal, meningococcal, and Haemophilus influenzae (Hib) vaccinations are indicated for patients after splenectomy. These immunizations should be given at least 14 days before a scheduled splenectomy, or given after the fourteenth postoperative day (strength of recommendation [SOR]: A, based on systematic review of RCTs for the pneumococcal vaccine; SOR: B, based on systematic review of clinical trials for meningococcal and Hib vaccines)

How should we manage infants at risk for group B streptococcal disease?

Asymptomatic term infants whose mothers received adequate intrapartum antibiotic prophylaxis (defined as intravenous penicillin or ampicillin at least 4 hours before delivery) for group B streptococcal disease do not need work-up or treatment (strength of recommendation [SOR]: B, based on retrospective, population-based study). These infants should be observed for 48 hours, but may be discharged after 24 hours in circumstances where close follow-up is available (SOR: D, based on expert opinion). Symptomatic infants, premature infants (gestational age <35 weeks) of mothers who did not receive prophylaxis, and infants whose mothers had chorioamnionitis should receive a full evaluation (complete blood count, blood culture, and chest x-ray with or without a lumbar puncture) and an initial empiric antibiotic treatment with ampicillin or penicillin and gentamycin. If a term infant is not symptomatic and maternal antibiotic prophylaxis was not adequate, opinions differ as to whether to perform limited evaluation with empiric treatment or close observation (SOR: D, based on expert opinion)

Do statins cause myopathy?

If statins (HMG-CoA reductase inhibitors) cause myopathy, the risk is very low (strength of recommendation [SOR]: A). There is no direct evidence to answer this question. A pooled analysis of randomized controlled trials found similar myopathy rates in patients taking statins and placebo. However, a large cohort study revealed a very small but statistically significant increased risk of myopathy in patients taking statins (number needed to harm=10,000/year). Case reports suggest a myopathy risk for all statins, including fatal rhabdomyolysis. Risk of myopathy may increase with higher statin doses, certain comorbid states (eg, hypothyroidism, renal insufficiency [especially with diabetes], recent trauma, perioperative periods, advanced age, small body frame) and concurrent medications, including fibrates, cyclosporine, azole antifungals, and macrolide antibiotics (SOR: B). No studies have directly compared myopathy rates among statins, and there is no good evidence to suggest any differences. No controlled study has directly examined statin rechallenge in patients with previous myopathy; however, case reports and expert opinion support this practice (SOR: B)

What blood tests help diagnose celiac disease?

Histological confirmation of infiltrative lesions via small bowel biopsy is the gold standard for diagnosing celiac disease. Four serum antibody assays may serve as a first- step diagnostic tool to identify biopsy candidates: immunoglobulin A tissue transglutaminase (IgA tTG), IgA endomysial antibody (IgA EMA), IgA antigliadin antibody (IgA AGA), and IgG antigliadin antibody (IgG AGA). IgA tTG and IgA EMA offer the best diagnostic accuracy. Patients with selective IgA deficiency may have falsely negative IgA assays (strength of recommendation [SOR]: B, based on a systematic review, multiple small cross-sectional studies, and expert opinion)

What is the role of prokinetic agents for constipation?

Erythromycin has a limited role in treating pediatric patients (strength of recommendation [SOR]: B, limited-quality, patient-oriented evidence). Tegaserod and cisapride are the only prokinetic agents available for constipated adults (SOR: A, consistent, good-quality, patient-oriented evidence for tegaserod; SOR: B, for cisapride), but cardiovascular risk restricts prescribing of both medications

What medications are best for diabetic neuropathic pain?

Tricyclic antidepressants, duloxetine, pregabalin, oxycodone, and tramadol are all effective for the symptomatic treatment of painful diabetic neuropathy (strength of recommendation [SOR]: A, systematic reviews of randomized controlled trials [RCTs] and single RCTs). Gabapentin is also effective (SOR: B, systematic review of RCTs with methodologic flaws). Studies directly comparing tricyclic antidepressants with gabapentin or duloxetine show equivalent efficacy (SOR: A, systematic reviews of RCTs and single RCTs). The outcome evaluated in all of these studies was pain

What risk factors contribute to C difficile diarrhea?

Certain antibiotics and using 3 or more antibiotics at one time are associated with Clostridium difficile-associated diarrhea (CDAD) (strength of recommendation [SOR]: B, 1 heterogeneous systematic review and several good-quality cohort studies). Hospital risk factors include proximity to other patients with C difficile and longer length of stay (SOR: B, several good-quality cohort studies). Patient risk factors include advanced age and comorbid conditions (SOR: B, several good-quality cohort studies). Acid suppression medication is also a risk factor for CDAD (SOR: B, 1 heterogeneous systematic review and 2 good-quality cohort studies)

Undergoing varicocele repair before assisted reproduction improves pregnancy rate and live birth rate in azoospermic and oligospermic men with a varicocele: a systematic review and meta-analysis

OBJECTIVE: To evaluate how varicocele repair (VR) impacts pregnancy (PRs) and live birth rates in infertile couples undergoing assisted reproduction wherein the male partner has oligospermia or azoospermia and a history of varicocele. DESIGN: Systematic review and meta-analysis. SETTING: Not applicable. PATIENT(S): Azoospermic and oligospermic males with varicoceles and in couples undergoing assisted reproductive technology (ART) with IUI, IVF, or testicular sperm extraction (TESE) with IVF and intracytoplasmic sperm injection (ICSI). INTERVENTION(S): Measurement of PRs, live birth, and sperm extraction rates. MAIN OUTCOME MEASURE(S): Odds ratios for the impact of VR on PRs, live birth, and sperm extraction rates for couples undergoing ART. RESULT(S): Seven articles involving a total of 1,241 patients were included. Meta-analysis showed that VR improved live birth rates for the oligospermic (odds ratio [OR] = 1.699) and combined oligospermic/azoospermic groups (OR = 1.761). Pregnancy rates were higher in the azoospermic group (OR = 2.336) and combined oligospermic/azoospermic groups (OR = 1.760). Live birth rates were higher for patients undergoing IUI after VR (OR = 8.360). Sperm retrieval rates were higher in persistently azoospermic men after VR (OR = 2.509). CONCLUSION(S): Oligospermic and azoospermic patients with clinical varicocele who undergo VR experience improved live birth rates and PRs with IVF or IVF/ICSI. For persistently azoospermic men after VR requiring TESE for IVF/ICSI, VR improves sperm retrieval rates. Therefore, VR should be considered to have substantial benefits for couples with a clinical varicocele even if oligospermia or azoospermia persists after repair and ART is required

Knowing When to Stop: Final Results vs. Work Involved in Systematic Review Database Searching

Objectives: To examine the relationship between the amount of work involved for the systematic review (SR) team for each additional database searched in an SR versus the number of unique articles included in the final review that were retrieved from each additional database searched. Methods: We reviewed SRs and meta-analyses published in JAMA, Lancet, and Annals of Internal Medicine from January 2012 to December 2015, selecting those journals as high impact factor journals that have published over more than 50 SRs per year since 2012. We required that all papers in our analysis report a complete search strategy, with the total number of citations retrieved from each database and a complete list of articles included in the final analysis. We then used lists of included journals from each database to determine in which database(s) each of the included articles were indexed, and we calculated the percentage of articles included in each SR that could be located by searching each database. We then compared the number of results added by searching each additional database to the total number of papers added to the review phase to estimate the amount of work required for each additional paper identified. Results: Ninety-seven SRs met our inclusion criteria. These SRs included an average of 48.13 journal articles and searched an average of 4.43 databases each. Of these, the journal articles included in 16 SRs could all be found in one database; the articles included in 58 SRs could all be found in two databases. For 20 SRs, all included articles could be found in three databases, and the remaining three SRs included articles that could be found in four databases. For 96 SRs, over 90% of articles could be found in two databases. Conclusions: In total, 99% of articles included in each SR were found in two databases, with the majority being found in PubMed/MEDLINE, Embase, or Cochrane. SRs that found articles in three or more databases screened an additional 923 records in order to find one additional included article, plus an additional 2410 records from databases that did not return any additional included articles, adding an average of 756 hours of work to each SR. SRs for which articles were found in four databases screened an average of 1440 records in order to find one additional included article, plus an additional 8963 records from databases that did not return any additional included articles