What is the best beta-blocker for systolic heart failure?

Q: What is the best beta-blocker for systolic heart failure? Evidence-based answer: Three beta-blockers--carvedilol, metoprolol succinate, and bisoprolol--reduce mortality equally (by about 30% over one year) in patients with Class III or IV systolic heart failure. Insufficient evidence exists comparing equipotent doses of these medications head-to-head to recommend any one over the others (strength of recommendation [SOR]: A, systematic review/meta-analysis)

Does surgery relieve the pain of a herniated disc?

Patients with an acute episode of low back pain, radicular symptoms, and evidence of a herniated disc on imaging may experience short-term pain relief from discectomy if their symptoms haven�۪t improved after initial conservative therapy (strength of recommendation [SOR]: A, multiple randomized, controlled trials [RCTs]). Although surgery may enhance pain relief initially, no evidence supports a long-term benefit for surgery over conservative management (SOR: A, multiple RCTs)

What are the benefits and risks of daily low-dose aspirin for primary prevention of CV events?

Q: What are the benefits and risks of daily low-dose aspirin for primary prevention of CV events? A: One nonfatal myocardial infarction (MI) will be avoided for every 126 to 138 adults who take daily aspirin for 10 years (strength of recommendation [SOR]: A, systematic reviews and meta-analyses of multiple randomized controlled trials [RCTs]). Taking low-dose aspirin for primary prevention shows no clear mortality benefit. A benefit for primary prevention of stroke is less certain. Although no evidence establishes increased risk of hemorrhagic stroke from daily low-dose aspirin, one gastrointestinal hemorrhage will occur for every 72 to 357 adults who take aspirin for longer than 10 years (SOR: A, systematic reviews and meta-analyses of multiple RCTs and cohort studies).Authors: Justin Mutter, MD, MSc University of Virginia School of Medicine, Charlottesville; Rebecca Grandy, PharmD, BCACP, CPP Mountain Area Health Education Center, Asheville, NC, and Eshelman School of Pharmacy, University of North Carolina-Chapel Hill, Asheville; Stephen Hulkower, MD Mountain Area Health Education Center, Asheville, NC; Sue Stigleman, MLS Mountain Area Health Education Center, Asheville

Do preparticipation clinical exams reduce morbidity and mortality for athletes?

Though clinical preparticipation exams (PPE) are recommended by experts and required in most states, we found no medium- or better-quality evidence that demonstrates they reduce mortality or morbidity. PPEs detect only a very small percentage of cardiac abnormalities among athletes who subsequently die suddenly (strength of recommendation [SOR]: C, case series study). PPEs are also unable to accurately identify athletes with exercise-induced bronchospasm (SOR: C, small cross-sectional study) and are poorly predictive of which athletes are at increased risk of orthopedic injuries (SOR: C, cross-sectional study)

Effect of corticosteroids on pain and function in knee osteoarthritis patients

Clinical Inquiries question: Does the type of corticosteroid have an effect on pain and functional status of the knee in osteoarthritis (OA) patients receiving intra-articular injections? Evidence-based answer: In patients with knee OA, the type of injected steroid does not appear to alter pain and functional response, based on 3 head-to-head trials comparing intra-articular injection of different corticosteroid formulations for relief of knee pain and improvement of functional status (strength of recommendation A: based on small randomized controlled trials with consistent results).Luke Beggs, MD, PhD; Sue Stigleman, MLS; Aaron Vaughan, MD; Josh Pacious, DO; Stephen Hulkower, MDDr Beggs is a resident in the Family Medicine Residency Program at Mountain Area Health Education Center (MAHEC) in Asheville, NC. Ms Stigleman is a medical librarian for University of North Carolina Health Sciences at MAHEC. Dr Vaughan is Fellowship Program Director of Primary Care Sports Medicine at MAHEC. Dr Pacious is a resident in the Family Medicine Residency Program at MAHEC. Dr Hulkower is Chair of the Department of Family Medicine for University of North Carolina Health Sciences at MAHEC.Includes bibliographical reference

How often does long-term PPI therapy cause clinically significant hypomagnesemia?

Q: How often does long-term PPI therapy cause clinically significant hypomagnesemia? EVIDENCE-BASED ANSWER: Rarely. Proton pump inhibitors (PPIs) may be associated with decreases in serum magnesium laboratory values to below 1.6 to 1.8 mg/dL, especially when used concurrently with diuretics and loop diuretics (strength of recommendation [SOR]: C, disease-oriented outcomes based on cohort, case-control, and cross-sectional studies). Clinically significant or symptomatic hypomagnesemia (below 1.2 mg/dL) appears to be quite rare, however.Timothy Plaut, MD; Katelyn Graeme, DO; Sue Stigleman, MLS; Stephen Hulkower, MD, Mountain Area Health Education Center, Asheville, NC ; Tasha Woodall, PharmD, Mountain Area Health Education Center, Asheville, NC; Eshelman School of Pharmacy, University of North Carolina, Chapel Hill

Are steroid injections effective for tenosynovitis of the hand?

Yes. Steroid injections are an effective first-line therapy for flexor tenosynovitis of the hand, with a number needed to treat [NNT] of 2.3 for injection of steroids and lidocaine (strength of recommendation [SOR]: B, based on 1 prospective RCT and low- quality studies). Injection into the tendon sheath may not be critical to a successful outcome (SOR: B, based on 1 prospective uncontrolled trial)

What's the best treatment for sebaceous cysts?

Punch biopsy excision appears to be superior to traditional wide elliptical excision for the treatment of sebaceous cysts when intervention is necessary (strength of recommendation [SOR]: B, based on 1 small randomized study). No rigorous metho- dological studies have compared punch biopsy excision of sebaceous cysts with the minimal excision technique

Which oral nonopioid agents are most effective for OA pain?

Q Which oral nonopioid agents are most effective for OA pain? Evidence-based answer: nonsteroidal anti-inflammatory drugs (nsaids), when used at the maximum clinically effective dose, reduce osteoarthritis (OA) pain in large joints more effectively than either placebo or acetaminophen (strength of recommendation [SOR]: A, network meta-analysis of randomized controlled trials [RCTs]). When ranked for efficacy, diclofenac 150 mg/d was the most effective (SOR: A, network meta-analysis of RCTs). The selective COX-2 inhibitors, such as celecoxib, are not more effective at reducing pain than the nonselective NSAIDs (SOR: A, metaanalysis of RCTs). Meloxicam is superior to placebo but marginally inferior to other NSAIDs (SOR: A, systematic review of RCTs). Acetaminophen is no more effective than placebo (SOR: A, meta-analysis of RCTs).Benjamin Gilmer, MD, MS; Stephen Hulkower, MD, UNC Health Sciences at MAHEC, Asheville, NC ; Courtenay Gilmore Wilson, PharmD, BCPS, BCACP, CDE, CPP, UNC Health Sciences at MAHEC, Asheville, NC; Eshelman School of Pharmacy, University of North Carolina-Chapel Hill ; Brittney Macdonald, MD, MAHEC Family Medicine Residency Program, Asheville, NC ; Jonathan Pozner, MS4, University of North Carolina School of Medicine-Asheville ; Sue Stigleman, MLS, Mountain Area Health Education Center, Asheville, NC.Includes bibliographical reference

Does XR injectable naltrexone prevent relapse as effectively as daily sublingual buprenorphine-naloxone?

Q: Does XR injectable naltrexone prevent relapse as effectively as daily sublingual buprenorphine-naloxone? Evidence-based answer: Yes. Monthly extended-release injectable naltrexone (XR-NTX) treats opioid use disorder as effectively as daily sublingual buprenorphine-naloxone (BUP-NX) without causing any increase in serious adverse events or fatal overdoses. (strength of recommendation: A, 2 good-quality RCTs).Matthew Roe, MD (Mountain Area Health Education Center (MAHEC), Asheville, NC); Courtenay Gilmore Wilson, PharmD, BCPS, BCACP, CDE, CPP (Eshelman School of Pharmacy, University of North Carolina Health Sciences at MAHEC, Asheville) Carriedelle Wilson Fusco, FNP-BC; Stephen Hulkower, MD (University of North Carolina Health Sciences at MAHEC, Asheville); Sue Stigleman, MLS (University of North Carolina Health Sciences at MAHEC, Asheville)Includes bibliographical reference