Should RAAS blockade therapy be continued in patients with advanced renal disease?

Q: Should RAAS blockade therapy be continued in patients with advanced renal disease? Evidence-based answer: PROBABLY. Renin-angiotensinaldosterone system (RAAS) blockade therapy should be continued in most patients with advanced renal disease and comorbid conditions; however, individualized treatment is warranted as data on the benefits and harms in all-cause mortality, cardiovascular mortality, and risk for renal replacement therapy are inconclusive (strength of recommendation [SOR]: B, based on observational studies, systematic reviews, and meta-analyses of randomized controlled trials [RCTs]). Certain patient populations, such as patients with diabetes or those with cardiovascular risk or history, may benefit most from continued RAAS blockade therapy (SOR: A, based on systematic reviews and meta-analyses of RCTs).Kim Pham, DO; Carli Beyer, DO (Methodist Charlton Family Medicine Residency), Rick Guthmann, MD, (MPH Advocate Health Care Illinois Masonic Medical Center Program)Includes bibliographical reference

What is the most effective treatment for scabies?

Q: What is the most effective treatment for scabies? Evidence-based answer: Topical permethrin is the most effective treatment for classic scabies (strength of recommendation [SOR]: A, meta-analyses with consistent results). Topical lindane and crotamiton are inferior to permethrin but appear equivalent to each other and benzyl benzoate, sulfur, and natural synergized pyrethrins (SOR: B, limited randomized trials). Although not as effective as topical permethrin, oral ivermectin is an effective treatment compared with placebo (SOR: B,a single small randomized trial). Oral ivermectin may reduce the prevalence of scabies at one year in populations with endemic disease more than topical permethrin (SOR: B, a single randomized trial)

Does physical exercise reduce dementia-associated agitation?

Q: Evidence-based answer: not consistently. Physical exercise demonstrates inconsistent benefit for neuropsychiatric symptoms, including agitation, in patients with dementia (strength of recommendation: b, inconsistent meta-analyses, 2 small randomized controlled trials [RCTs]). The care setting and the modality, frequency, and duration of exercise varied across trials; the impact of these factors is not known.Katarzyna Jabbour, PharmD, BCPS; Lynn M. Wilson, DO, FACOFP, FAAFP; Susan S. Mathieu, MD; Drew Keister, MD, FAAFP (Lehigh Valley Health Network Family Medicine Residency Program (Lehigh)), Rick Guthmann, MD, MPH (Advocate Health Care Illinois Masonic Medical Center Program)Includes bibliographical reference

How accurate is transcutaneous bilirubin testing in newborns with darker skin tones?

Q: How accurate is transcutaneous bilirubin testing in newborns with darker skin tones? Evidence-based answer: Fairly accurate. Photometric transcutaneous bilirubin (TcB) testing may overestimate total serum bilirubin (TSB) in neonates with darker skin tones by a mean of 0.68 to > 2 mg/dL (strength of recommendation [SOR]: C, diagnostic cohort studies with differing reference standards). Overall, TcB meters retain acceptable accuracy in infants of all skin tones across a range of bilirubin levels, despite being more likely to underestimate lighter skin tones and overestimate darker ones (SOR: C, diagnostic cohort studies with differing reference standards). It is unclear if the higher readings prompt an increase in blood draws or otherwise alter care.Brandi Boden, DO; Brittany Buescher, MD; Amanda Kim, MD; Jon O. Neher, MD (Valley Family Medicine Residency, University of Washington), Sarah Safranek (MLIS Librarian Emeritus, University of Washington, Seattle), Rick Guthmann (MD, MPH Advocate Health Care Illinois Masonic Medical Center Program)Includes bibliographical reference

Does hormone replacement therapy prevent cognitive decline in postmenopausal women?

Q: Evidence-based answer: NO. Hormone replacement therapy (HRT) does not prevent cognitive decline in postmenopausal women—and in fact, it may slightly increase risk (strength of recommendation, A; systematic review, meta-analysis of randomized controlled trials [RCTs], and individual RCT).Madeline Gates, MD; Melissa Beagle, MD, MPH; Lauren Bull, MD; Roxanne Radi, MD, MPH; Corey Lyon, DO (University of Colorado, Family Medicine Residency), Kristen DeSanto, MSLS, MS, RD (University of Colorado, Health Sciences Library), Rick Guthmann, MD, MPH (Advocate Health Care Illinois Masonic Medical Center Program)Includes bibliographical reference

Does regular walking improve lipid levels in adults?

Q: Evidence-based answer: Minimally. Regular moderateintensity walking for a period of 4 or more weeks minimally decreased total cholesterol (TC) and low-density lipoprotein (LDL) levels by about 7 mg/dL in women with overweight or obesity (strength of recommendation [SOR]: C, systematic review and meta-analysis on disease-oriented evidence). For adults ages 40 to 65 years, regular walking for 3 or more months inconsistently affected cholesterol and triglyceride levels (SOR: C, based on 3 randomized controlled trials [RCTs] with disease-oriented evidence).Kayla Hatchell, MD; Emily Chin, DO; Brian Vukelic, MD; Katherine Fortenberry, PhD; Dominick Ose, DrPH; Eliza Taylor, MPH, BS, CHES; Rachel Goossen, MD (University of Utah), Rick Guthmann, MD, MPH (Advocate Health Care Illinois Masonic Medical Center Program)Includes bibliographical reference

Baseline data of parasite clearance in patients with falciparum malaria treated with an artemisinin derivative: an individual patient data meta-analysis.

BACKGROUND: Artemisinin resistance in Plasmodium falciparum manifests as slow parasite clearance but this measure is also influenced by host immunity, initial parasite biomass and partner drug efficacy. This study collated data from clinical trials of artemisinin derivatives in falciparum malaria with frequent parasite counts to provide reference parasite clearance estimates stratified by location, treatment and time, to examine host factors affecting parasite clearance, and to assess the relationships between parasite clearance and risk of recrudescence during follow-up. METHODS: Data from 24 studies, conducted from 1996 to 2013, with frequent parasite counts were pooled. Parasite clearance half-life (PC1/2) was estimated using the WWARN Parasite Clearance Estimator. Random effects regression models accounting for study and site heterogeneity were used to explore factors affecting PC1/2 and risk of recrudescence within areas with reported delayed parasite clearance (western Cambodia, western Thailand after 2000, southern Vietnam, southern Myanmar) and in all other areas where parasite populations are artemisinin sensitive. RESULTS: PC1/2 was estimated in 6975 patients, 3288 of whom also had treatment outcomes evaluate d during 28-63 days follow-up, with 93 (2.8 %) PCR-confirmed recrudescences. In areas with artemisinin-sensitive parasites, the median PC1/2 following three-day artesunate treatment (4 mg/kg/day) ranged from 1.8 to 3.0 h and the proportion of patients with PC1/2 >5 h from 0 to 10 %. Artesunate doses of 4 mg/kg/day decreased PC1/2 by 8.1 % (95 % CI 3.2-12.6) compared to 2 mg/kg/day, except in populations with delayed parasite clearance. PC1/2 was longer in children and in patients with fever or anaemia at enrolment. Long PC1/2 (HR = 2.91, 95 % CI 1.95-4.34 for twofold increase, p < 0.001) and high initial parasitaemia (HR = 2.23, 95 % CI 1.44-3.45 for tenfold increase, p < 0.001) were associated independently with an increased risk of recrudescence. In western Cambodia, the region with the highest prevalence of artemisinin resistance, there was no evidence for increasing PC1/2 since 2007. CONCLUSIONS: Several factors affect PC1/2. As substantial heterogeneity in parasite clearance exists between locations, early detection of artemisinin resistance requires reference PC1/2 data. Studies with frequent parasite count measurements to characterize PC1/2 should be encouraged. In western Cambodia, where PC1/2 values are longest, there is no evidence for recent emergence of higher levels of artemisinin resistance

Is there benefit to adding ezetimibe to a statin for the secondary prevention of CVD?

Q: Is there benefit to adding ezetimibe to a statin for the secondary prevention of CVD? Evidence-based answer: YES. In patients with known cardiovascular disease (CVD), ezetimibe with a statin decreases major adverse cardiovascular events (MACE) but has no effect on all-cause and cardiovascular mortality, compared to a statin alone (strength of recommendation [SOR], A; meta-analysis of randomized controlled trials [RCTs] including 1 large RCT). In adults with atherosclerotic CVD (ASCVD), the combination of ezetimibe and a moderate-intensity statin (rosuvastatin 10 mg) was noninferior at decreasing cardiovascular death, major cardiovascular events, and nonfatal stroke, but was more tolerable, compared to a high-intensity statin (rosuvastatin 20 mg) alone (SOR, B; 1 RCT).Vinay Reddy, MD; James Allison, MD; Anne Mounsey, MD (Department of Family Medicine, University of North Carolina). Deputy Editor: Rick Guthmann, MD, MPH (Advocate Health Care Illinois Masonic Medical Center Program).Includes bibliographical reference

Are manual therapies effective at reducing chronic tension headache frequency in adults?

MAYBE. Among patients with chronic tension headaches, manual therapies may reduce headache frequency more than sham manual therapy, usual care, or exercise treatments-by 1.5 to 4.2 headaches or days with headache per week (strength of recommendation, B; preponderance of evidence from primarily small, heterogeneous randomized controlled trials [RCTs])

How does gender-affirming hormone therapy affect QOL in transgender patients?

Q: How does gender-affirming hormone therapy affect QOL in transgender patients? Evidence-based answer: There are modest effects on depression but not anxiety. Gender-affirming hormone therapy (GAHT) is associated with modest improvements in standardized scores for quality of life (QOL) and depression in adult male-to-female and female-to-male transgender people and modest improvements in depression scores in transgender adolescents, but the effect on anxiety is uncertain (strength of recommendation [SOR]: B, based on a preponderance of low-quality prospective cohort studies with inconsistent results). GAHT is associated with reduced gender dysphoria and decreased suicidality (SOR: B, based on a prospective cohort study). However, there is insufficient evidence to determine any effect on suicide completion. No studies associated GAHT with worsened QOL, depression, or anxiety scores.Sarah Wilhelm, MD; Gary Kelsberg, MD (Providence Family Medicine Residency Spokane, University of Washington) Sarah Safranek, MLIS (Librarian Emeritus, University of Washington Health Sciences Library), Rick Guthmann, MD, MPH (Advocate Health Care Illinois Masonic Medical Center Program)Includes bibliographical reference