Do ACE inhibitors decrease mortality in patients with hypertension?

When used to treat patients with hypertension, ACE inhibitors reduce cardiovascular and all-cause mortality as effectively as diuretics, beta blockers, and calcium channel blockers. [Strength of recommendation: A, based on meta-analyses of randomized controlled trials (RCTs) with patient-oriented outcomes

What is the most effective beta-blocker for heart failure?

Three beta-blockers--carvedilol, metoprolol, and bisoprolol--reduce mortality in chronic heart failure caused by left ventricular systolic dysfunction, when used in addition to diuretics and angiotensin converting enzyme (ACE) inhibitors (strength of recommendation [SOR]: A, based on large randomized placebo-controlled trials). No differences in mortality or patient tolerance have been demonstrated in studies comparing carvedilol and metoprolol (SOR: B, based on small head-to-head trials)

What is the best therapy for superficial thrombophlebitis?

For proximal saphenous vein thrombosis, anticoagulation is more effective than venous ligation (with or without stripping) in preventing deep venous thrombosis (DVT) and pulmonary embolus (PE) (strength of recommendation [SOR]: C, qualitative systematic review of primarily case series). For patients with superficial venous thrombophlebitis (SVTP) distal to the saphenous vein of the thigh, tenoxicam (a nonsteroidal anti-inflammatory agent [NSAID]) and low-molecular-weight heparin are similarly effective for reducing extension and subsequent DVT when administered along with compression therapy (SOR: B, 1 randomized controlled trial). Oral or topical NSAIDs, topical heparin, and topical nitroglycerin all alleviate symptoms and speed resolution of SVTP caused by infusion catheters (SOR: B, smaller, occasionally conflicting randomized trials)

What is the best macrolide for atypical pneumonia?

Erythromycin, clarithromycin, and azithromycin are equally effective in treating pneumonia caused by Mycoplasma pneumoniae or Chlamydophila (formerly Chlamydia) pneumoniae (strength of recommendation [SOR]: B, small head-to-head trials). Macrolide choice can be based on other considerations--cost, side effects, and effectiveness against other suspected pathogens (SOR: C, expert opinion)

Do group visits improve HbA1c more than individual visits in patients with T2DM?

E21-E22.Do group visits improve HbA1c more than individual visits in patients with T2DM? Evidence-based answer: Yes. In patients with type 2 diabetes mellitus (T2DM), group visits led by health professionals or teams improved glycosylated hemoglobin (HbA1c) by 0.3% to 0.9% over usual care (strength of recommendation [SOR]: B, meta-analyses of randomized clinical trials [RCTs] with moderate to high risk of bias). Patients taking oral antidiabetic agents alone appear to benefit more than patients on insulin. Peer-led group visits likely have no effect (SOR: B, subgroup analysis within a meta-analysis). Treatment durations as long as 3 years are associated with larger decreases in HbA1c (by 0.25% per year) than treatment lasting less than a year (SOR: B, meta-analysis of RCTs involving patents with type 1 diabetes and T2DM). Patients with T2DM should be offered group visits for diabetes education when available (SOR: C, expert opinion).Amanda Berbert, MD; Jon Neher, MD (Valley Family Medicine Residency, University of Washington at Valley Medical Center, Renton); Sarah Safranek, MLIS (University of Washington, Health Sciences Library, Seattle)Includes bibliographical reference

How effectively do ACE inhibitors and ARBs prevent migraines?

Q: How effectively do ACE inhibitors and ARBs prevent migraines? Evidence-based answer: The angiotensin-converting enzyme (ACE) inhibitor lisinopril reduces the number of migraines by about 1.5 per month in patients experiencing 2 to 6 migraines monthly (strength of recommendation [SOR]: B, small cross-over trial); the angiotensin II receptor blocker (ARB) candesartan may produce a similar reduction (SOR: C, conflicting crossover trials). Considered as a group, ACE inhibitors and ARBs have a moderate to large effect on the frequency of migraine headaches (SOR: B, meta-analysis of small clinical trials), although only lisinopril and candesartan show fair to good evidence of efficacy. Providers may consider lisinopril or candesartan for migraine prevention, taking into account their effect on other medical conditions (SOR: C, expert opinion).Brendan Morris MD; Jon Neher MD, Valley Family Medicine Residency, University of Washington at Valley Medical Center, Renton ; Sarah Safranek, MLIS, University of Washington, Health Sciences Library, Seattle

Effective analgesic options for intrauterine device placement pain

Clinical Inquiries question: What analgesic options are most effective for pain related to intrauterine device (IUD) placement? Evidence-based answer: Lidocaine-prilocaine cream (LPC; 2.5% lidocaine and 2.5% prilocaine) reduces the pain of tenaculum placement by 24% and IUD insertion by 28% (strength of recommendation [SOR] A: consistent meta-analyses of randomized controlled trials [RCTs]). Giving 600 μg of vaginal misoprostol 6 hours before insertion and applying 4% viscous lidocaine solution to the cervix within 5 minutes of IUD placement might reduce pain, but by less than 20% (SOR B: RCTs). Pretreatment with 2% topical lidocaine gels, 400 μg of misoprostol, or ibuprofen is not effective in reducing pain (SOR A: metaanalyses of RCTs). Buffered lidocaine paracervical blocks might also be helpful to reduce overall pain (SOR C: conflicting meta-analyses and an RCT).Karena Whitworth, MD; Jon Neher, MD; Sarah Safranek, MLISDr Whitworth is a family physician at Family Health Associates in Bellingham, Wash. Dr Neher is Associate Director of Curriculum Development at Valley Family Medicine in Renton, Wash. Ms Safranek is Information Management Librarian at the University of Washington in Seattle.Includes bibliographical reference

Does antepartum perineal massage reduce intrapartum lacerations?

Yes--to a point. Antepartum perineal massage reduces both the incidence of perineal trauma requiring suturing and the likelihood of episiotomy in women who have never given birth vaginally. It reduces the incidence of postpartum perineal pain in women who have given birth vaginally. Perineal massage doesn't reduce the frequency of first- or second-degree lacerations or third- and fourth-degree perineal trauma. (Strength of recommendation [SOR]: A, systematic review of randomized controlled trials [RCTs].

When are antibiotics indicated for acute COPD exacerbations?

Antibiotics (including those given orally) reduce mortality and treatment failures for hospitalized patients with acute exacerbations of chronic obstructive pulmonary disease (COPD) (strength of recommendation [SOR]: A, based on systematic reviews). Antibiotics may be prescribed in the outpatient setting for those with severe exacerbations (SOR: C, based on expert opinion)

Do pedometers increase activity and improve health outcomes?

Q: Do pedometers increase activity and improve health outcomes? Evidence-based answer: yes. In overweight and obese patients, exercise interventions using a pedometer increase steps by about a mile per day over the same interventions without access to pedometer information (strength of recommendation [SOR]: A, meta-analysis of randomized controlled trials [RCTs]) and are associated with a modest 4 mm Hg reduction in systolic blood pressure (BP) over baseline (SOR: B, meta-analysis of RCTs and cohort studies). In overweight patients with diabetes, pedometer use with nutritional counseling is associated with 0.86 kg greater weight loss than nutritional counseling alone (SOR: B, meta-analysis of lower quality RCTs). Pedometers increase activity in patients with various musculoskeletal conditions and may help reduce pain (SOR: B, meta-analysis of RCTs with heterogeneous outcomes). In low-activity elderly patients, pedometers do not appear to increase total activity when added to an exercise program, but they do appear to increase walking (SOR: B, RCT). There is no evidence concerning the impact of pedometers on cardiovascular outcomes