When should a chest x-ray be used to evaluate acute-onset productive cough for adults?

Even though the most common reason to order a chest x-ray in the evaluation of an acute-onset, productive cough is to rule out pneumonia, there is no strong evidence to help a physician decide when to order this chest x-ray. However, acute cough patients who have rhinorrhea, sore throat, respiratory rate ≤25 breaths per minute, temperature <100°F, and the absence of night sweats, myalgia, and all-day sputum production, have minimal to no risk of pneumonia and thus do not need a chest x-ray (strength of recommendation: A, based on a clinical decision rule validated in 2 high-quality cohort studies)

How does VTE risk for the patch and vaginal ring compare with oral contraceptives?

Evidence is conflicting with regard to the comparative frequency of venous thrombolic events (VTE) among women using the transdermal patch when compared to an oral contraceptive (OC), even though the patch produces a relatively high serum ethinyl estradiol (EE) level (strength of recommendation [SOR]: C, conflicting cohort case-control studies). The vaginal ring has a risk of VTE comparable to that of an OC (SOR: B, 1 comparative study)

Do testosterone injections increase libido for elderly hypogonadal patients?

Yes, testosterone therapy is effective in improving libido for elderly hypogonadal males (strength of recommendation [SOR]: B, based on small randomized controlled trials [RCTs]). Testosterone combined with estrogen can also improve libido for postmenopausal women, but it's not approved by the US Food and Drug Administration (FDA) for this purpose (SOR: B, based on small R CTs)

What is the best way to treat tinea cruris?

After clinical diagnosis and microscopic confirmation, tinea cruris is best treated with a topical allylamine or an azole antifungal (strength of recommendation: A, based on multiple randomized controlled trials [RCTs]). Differences in current comparison data are insufficient to stratify the 2 groups of topical antifungals. Determining which group to use depends on patient compliance, medication accessibility, and cost. The fungicidal allylamines (naftifine and terbinafine) and butenafine (allylamine derivative) are a more costly group of topical tinea treatments, yet they are more convenient as they allow for a shorter duration of treatment compared with fungistatic azoles (clotrimazole, econazole, ketoconazole, oxiconazole, miconazole, and sulconazole)

How best to diagnose iron-deficiency anemia in patients with inflammatory disease?

The serum ferritin level is the most sensitive and specific initial laboratory test for iron- deficiency anemia (IDA) in patients with inflammation. Serum ferritin levels <45 ng/dL confirm IDA, and levels of ≥100 ng/dL essentially rule it out (strength of recommendation [SOR]: B, systematic review of prospective validating cohort studies with heterogeneity). For patients with intermediate serum ferritin levels (45-99 ng/dL), the soluble transferrin receptor (sTfR) level and the sTfR-ferritin index (ratio of sTfR to log ferritin) are highly sensitive and specific. An sTfR-ferritin index of ≥1.5 is diagnostic of IDA, even in the presence of acute or chronic inflammation (SOR: B, systematic review of prospective validating cohort studies that lacked standardized reference values)

Can counseling prevent or treat postpartum depression?

In most cases, counseling does not prevent postpartum depression (PPD), though it can treat the disorder. Overall, psychosocial interventions don't offer a significantly greater benefit than standard care in preventing PPD--although studies do suggest a preventive benefit when the intervention is administered postnatally, in the home, and targeted toward individual at-risk women (strength of recommendation [SOR]: A, meta-analysis of 15 randomized, controlled trials [RCTs] and 1 subsequent RCT)

Which nutritional therapies are safe and effective for depression?

St. John's wort is effective for short-term relief of mild to moderate depression (strength of recommendation [SOR]: A; 1 systematic review). Its safety profile is superior to older antidepressants; data comparing it with newer antidepressants (such as selective serotonin reuptake inhibitors) are limited (SOR: A, 1 systematic review). A small but statistically significant clinical benefit has been demonstrated for saffron, lavender, borage, dan zhi xiao yao (SOR: B, 1 systematic review and 3 randomized controlled trials), folate (SOR: A, 1 systematic review), and S-adenosylmethionine (SAMe) (SOR: A, 1 meta-analysis and 1 systematic review). Most trials of these preparations were short and small, limiting the ability to detect adverse effects. Tryptophan (SOR: A, 1 systematic review) and 5-hydroxytryptophan (5-HTP) (SOR: A, 1 systematic review) have demonstrated superiority over placebo in alleviating symptoms of depression, but concerns exist about their safety. N-3 long-chain polyunsaturated fatty acids (n-3 PUFAs) and omega-3 fatty acids don't appear effective in treating major depressive disorder (SOR: A, 1 systematic review.

What's the best test for underlying osteomyelitis in patients with diabetic foot ulcers?

A: What's the best test for underlying osteomyelitis in patients with diabetic foot ulcers? A: Magnetic resonance imaging (MRI) has a higher sensitivity and specificity (90% and 79%) than plain radiography (54% and 68%) for diagnosing diabetic foot osteomyelitis. MRI performs somewhat better than any of several common tests--probe to bone (PTB), erythrocyte sedimentation rate (ESR) >70 mm/ hr, C-reactive protein (CRP) >14 mg/L, procalcitonin >0.3 ng/mL, and ulcer size >2 cm2--although PTB has the highest specificity of any test and is commonly used together with MRI. No studies have directly compared MRI with a combination of these tests, which may assist in diagnosis (strength of recommendation [SOR]: B, meta-analysis of cohort trials and individual cohort and case control trial). Experts recommend obtaining plain films when considering diabetic foot ulcers to evaluate for bony abnormalities, soft tissue gas, and foreign body; MRI should be considered in most situations when infection is suspected (SOR: B, evidence-based guidelines)

Mortality from gastrointestinal congenital anomalies at 264 hospitals in 74 low-income, middle-income, and high-income countries: a multicentre, international, prospective cohort study

Summary Background Congenital anomalies are the fifth leading cause of mortality in children younger than 5 years globally. Many gastrointestinal congenital anomalies are fatal without timely access to neonatal surgical care, but few studies have been done on these conditions in low-income and middle-income countries (LMICs). We compared outcomes of the seven most common gastrointestinal congenital anomalies in low-income, middle-income, and high-income countries globally, and identified factors associated with mortality. Methods We did a multicentre, international prospective cohort study of patients younger than 16 years, presenting to hospital for the first time with oesophageal atresia, congenital diaphragmatic hernia, intestinal atresia, gastroschisis, exomphalos, anorectal malformation, and Hirschsprung’s disease. Recruitment was of consecutive patients for a minimum of 1 month between October, 2018, and April, 2019. We collected data on patient demographics, clinical status, interventions, and outcomes using the REDCap platform. Patients were followed up for 30 days after primary intervention, or 30 days after admission if they did not receive an intervention. The primary outcome was all-cause, in-hospital mortality for all conditions combined and each condition individually, stratified by country income status. We did a complete case analysis. Findings We included 3849 patients with 3975 study conditions (560 with oesophageal atresia, 448 with congenital diaphragmatic hernia, 681 with intestinal atresia, 453 with gastroschisis, 325 with exomphalos, 991 with anorectal malformation, and 517 with Hirschsprung’s disease) from 264 hospitals (89 in high-income countries, 166 in middleincome countries, and nine in low-income countries) in 74 countries. Of the 3849 patients, 2231 (58·0%) were male. Median gestational age at birth was 38 weeks (IQR 36–39) and median bodyweight at presentation was 2·8 kg (2·3–3·3). Mortality among all patients was 37 (39·8%) of 93 in low-income countries, 583 (20·4%) of 2860 in middle-income countries, and 50 (5·6%) of 896 in high-income countries (p<0·0001 between all country income groups). Gastroschisis had the greatest difference in mortality between country income strata (nine [90·0%] of ten in lowincome countries, 97 [31·9%] of 304 in middle-income countries, and two [1·4%] of 139 in high-income countries; p≤0·0001 between all country income groups). Factors significantly associated with higher mortality for all patients combined included country income status (low-income vs high-income countries, risk ratio 2·78 [95% CI 1·88–4·11], p<0·0001; middle-income vs high-income countries, 2·11 [1·59–2·79], p<0·0001), sepsis at presentation (1·20 [1·04–1·40], p=0·016), higher American Society of Anesthesiologists (ASA) score at primary intervention (ASA 4–5 vs ASA 1–2, 1·82 [1·40–2·35], p<0·0001; ASA 3 vs ASA 1–2, 1·58, [1·30–1·92], p<0·0001]), surgical safety checklist not used (1·39 [1·02–1·90], p=0·035), and ventilation or parenteral nutrition unavailable when needed (ventilation 1·96, [1·41–2·71], p=0·0001; parenteral nutrition 1·35, [1·05–1·74], p=0·018). Administration of parenteral nutrition (0·61, [0·47–0·79], p=0·0002) and use of a peripherally inserted central catheter (0·65 [0·50–0·86], p=0·0024) or percutaneous central line (0·69 [0·48–1·00], p=0·049) were associated with lower mortality. Interpretation Unacceptable differences in mortality exist for gastrointestinal congenital anomalies between lowincome, middle-income, and high-income countries. Improving access to quality neonatal surgical care in LMICs will be vital to achieve Sustainable Development Goal 3.2 of ending preventable deaths in neonates and children younger than 5 years by 2030