99 research outputs found
What is the best diagnostic approach to postmenopausal vaginal bleeding in women taking hormone replacement therapy?
Women on standard estrogen/progestin hormone replacement therapy (HRT) regimens frequently have irregular bleeding during the first 12 months of treatment. Therefore, those taking HRT should usually be evaluated after 1 year of treatment if bleeding continues. (Grade of recommendation: C, based on case series.) Evaluation of this bleeding should begin with a pelvic examination and Papanicolaou (Pap) test (if not done in the previous 12 months), then transvaginal ultrasound (TVUS), followed by endometrial biopsy or hysteroscopy, if indicated. (Grade: B, based on a systematic review of studies.
Does psychiatric treatment help patients with intractable chronic pain?
Tricyclic antidepressants and intensive multidisciplinary programs are moderately effective for reducing chronic back pain; tricyclics are also effective for diabetic neuropathy and irritable bowel syndrome (strength of recommendation [SOR]: A, meta-analyses and multiple small randomized controlled trials). Cognitive therapies are modestly effective for reducing pain in the following: chronic back pain, other chronic musculoskeletal disorders including rheumatoid arthritis (SOR: B, multiple meta-analyses with significant heterogeneity), and for chronic cancer pain (SOR: B, 1 meta-analysis of various quality studies)
Do antiarrhythmics prevent sudden death in patients with heart failure?
Beta-blockers (class II antiarrhythmics) reduce sudden death and total mortality in patients with heart failure (strength of recommendation [SOR]: A, based on systematic reviews of randomized controlled trials). Amiodarone (class III) may reduce sudden death in heart failure (SOR: B, extrapolation from randomized controlled trials), but evidence is weak that it reduces total mortality, and it has significant side effects. Class I and other class III antiarrhythmic agents appear cause an increase in mortality due to sudden death in heart failure (SOR: B, extrapolations from randomized controlled trials)
What nonpharmacological treatments are effective against common nongenital warts?
Cryotherapy has similar cure rates to topical salicylate (a pharmacologic therapy) for non-genital common warts (strength of recommendation [SOR]: B, based on systemic review of variable quality randomized trials). Duct tape may be equivalent to cryotherapy (SOR: B, based on a single randomized trial). CO2 laser, photodynamic therapy, pulsed dye laser (PDL), and Er:Yag laser therapies may also be effective for recalcitrant warts (SOR: C, based on observational cohort studies)
How should we follow athletes after a concussion?
Athletes sustaining a concussion should be held from contact activities a minimum of 7 days; they must be asymptomatic and their coordination and neuropsychological tests should have returned to their pre-injury baseline (strength of recommendation [SOR]: B, based on multiple prospective cohort studies). High-risk athletes (eg, those with a history of previous concussion, high- school age or younger, or female) may need to avoid contact even after all these criteria are met (SOR: C, expert opinion)
Does case management improve diabetes outcomes?
Patients with type 2 diabetes benefit from case management, as evidenced by decreased glycated hemoglobin (HbA1c). The improvement in HbA1c appeared larger when case managers could make changes in medications independently and multidisciplinary teams were used (strength of recommendation [SOR]: C, 2 meta-analyses of randomized controlled trials [RCTs] with consistent disease-oriented findings). Patients with type 1 diabetes who have case management and "intense control" experience fewer cardiovascular events and decreased retinopathy and clinical neuropathy (SOR: B, 1 large, good-quality RCT)
Which medications benefit patients with diastolic heart failure?
Angiotensin-converting enzyme inhibitors (ACEIs), propranolol, statins, furosemide, and some angiotensin receptor blockers (ARBs) benefit patients. Medications that reduce mortality in diastolic heart failure include ACEIs (strength of recommendation [SOR]: C, 1 prospective cohort trial with matched controls), propranolol (SOR: B, 1 randomized controlled trial [RCT]), and statins (SOR: C, 1 prospective cohort trial). Furosemide improves symptoms of heart failure and quality of life (SOR: C, 1 RCT, using cohort data). ARBs show mixed results: candesartan decreases hospital admissions (SOR: B, 1 large RCT); losartan improves exercise duration and quality of life (SOR: B, 2 small RCTs); irbesartan doesn't improve heart failure symptoms or other outcomes (SOR: B, 1 large RCT)
When should patients with stroke receive thrombolytics?
Thrombolytic therapy should be limited to patients with acute ischemic stroke who meet strict inclusion and exclusion criteria and who can adhere to strict treatment protocol. Patients treated under these conditions have improved combined mortality and disability outcomes at 1 year when treated with recombinant tissue plasminogen activator (rtPA) (number needed to treat [NNT]=18; 95% confidence interval [CI], 11-56) (strength of recommendation [SOR]: B, meta-analysis of randomized controlled trials with significant heterogeneity)
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Reply to Ruan et al. (2017): Non-medical use of prescription opioids is associated with heroin initiation among US veterans.
We thank Ruan and colleagues for their letter and appreciate their comments regarding our recent study, which demonstrated an independent association between non-medical use of prescription opioids (NMUPO) and heroin initiation among US veterans
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Non-medical use of prescription opioids is associated with heroin initiation among US veterans: a prospective cohort study
Aims: To estimate the influence of non-medical use of prescription opioids (NMUPO) on heroin initiation among US veterans receiving medical care. Design: Using a multivariable Cox regression model, we analyzed data from a prospective, multi-site, observational study of HIV-infected and an age/race/site-matched control group of HIV-uninfected veterans in care in the United States. Approximately annual behavioral assessments were conducted and contained self-reported measures of NMUPO and heroin use. Setting: Veterans Health Administration (VHA) infectious disease and primary care clinics in Atlanta, Baltimore, New York, Houston, Los Angeles, Pittsburgh and Washington, DC. Participants: A total of 3396 HIV-infected and uninfected patients enrolled into the Veterans Aging Cohort Study who reported no life-time NMUPO or heroin use, had no opioid use disorder diagnoses at baseline and who were followed between 2002 and 2012. Measurements: The primary outcome measure was self-reported incident heroin use and the primary exposure of interest was new-onset NMUPO. Our final model was adjusted for socio-demographics, pain interference, prior diagnoses of post-traumatic stress disorder and/or depression and self-reported other substance use. Findings: Using a multivariable Cox regression model, we found that non-medical use of prescription opioids NMUPO was associated positively and independently with heroin initiation [adjusted hazard ratio (AHR) = 5.43, 95% confidence interval (CI) = 4.01, 7.35]. Conclusions: New-onset non-medical use of prescription opioids (NMUPO) is a strong risk factor for heroin initiation among HIV-infected and uninfected veterans in the United States who reported no previous history of NMUPO or illicit opioid use
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