What regimens eradicate Heliobacter pylori?

Fourteen-day triple therapy with a proton pump inhibitor (PPI) plus clarithromycin and either amoxicillin or metronidazole is superior to 7-day therapy in eradicating Heliobacter pylori (strength of recommendation [SOR]: A, highquality meta-analysis). Seven-day triple therapy with a PPI or ranitidine bismuth citrate plus clarithromycin and either amoxicillin or metronidazole is also effective (SOR: A, high-quality systematic review). Three-day quadruple therapy with a combination of PPI, clarithromycin, bismuth subcitrate, and metronidazole or a combination of PPI, clarithromycin, amoxicillin, and metronidazole also appears to be effective (SOR: B, unblinded randomized controlled trial)

Antiepileptic Drug Level Monitoring

Routine monitoring of antiepileptic drug levels does not alter seizure or side effect rates. (Strength of Recommendation [SOR]: B, based on a single randomized controlled trial [RCT] with less than 80 percent follow-up). Antiepileptic drug level monitoring may be clinically useful in special populations, including patients with suspected drug toxicity or noncompliance, pregnant patients, and patients with renal failure. Monitoring dosage increases of drugs with nonlinear kinetics, such as phenytoin (Dilantin), may be useful. (SOR: C, based on expert opinion). Therapeutic drug level monitoring of newer antiepileptic drugs has not been shown to be clinically useful. (SOR: C, based on expert opinion)

Should we discontinue Pap smear screening in women aged >65 years?

Women with a history of regular, normal Pap smear screening should discontinue screening by age 65 years (strength of recommendation [SOR]: B). Women without a history of serial normal Pap smears should continue screening (SOR: B)

What is the best hypnotic for use in the elderly?

Short-acting hypnotics such as zolpidem (Ambien) or zaleplon (Sonata) are the preferred hypnotics in the elderly because of an improved side-effect profile compared with traditional hypnotics such as benzodiazepines (strength of recommendation: B, based on extrapolations of randomized controlled trials). Zolpidem and zaleplon have a quick onset and short duration of action, making them less likely to cause residual sedation, cognitive changes, and falls than benzodiazepines. More comparative clinical trials in the elderly are needed to determine if zolpidem and zaleplon are truly safer than benzodiazepines in this population. Hypnotics should be prescribed on a short-term, intermittent basis as part of a comprehensive treatment plan that addresses any underlying causes of poor sleep

What is the differential diagnosis of chronic diarrhea in immunocompetent patients?

Case series from tertiary-care centers report toddler's diarrhea, cow's milk sensitivity enteropathy, infection, celiac disease, and idiopathic chronic diarrhea as the most common etiologies in the pediatric population. In adults, the most common etiologies were secretory diarrhea (idiopathic, laxative abuse, irritable bowel syndrome, diabetes mellitus, and fecal incontinence), malabsorption (pancreatic disease, noninflammatory short bowel syndrome, postgastrectomy, hyperthyroidism, and cholestasis), microscopic colitis, inflammatory bowel disease, celiac sprue, and radiation colitis. (Grade of recommendation: C, based on case series.

Can calcium supplements cause serious adverse effects in healthy people?

Calcium supplements with or without vitamin D increase the risk of myocardial infarction (MI), with numbers needed to harm (NNH) over 5 years of 69 to 240 (strength of recommendation [SOR]: B, meta-analyses of randomized controlled trials [RCTs] that evaluated a predominantly older female population and were limited by study designs). Calcium supplements with or without vitamin D may increase the risk of stroke, with an NNH over 5 years of 283 (SOR: B, meta-analyses of RCTs). Calcium supplementation, but not a diet rich in calcium, also increases the risk of renal calculi, with an NNH over 7 years of 272 (SOR: B, RCT and a cohort study, which also evaluated a predominantly older female population)

Is the long-term use of proton pump inhibitors safe?

Long-term use of proton pump inhibitors (PPIs) appears safe, resulting in no clinically relevant adverse effects (strength of recommendation: B, based on nonsystematic reviews, cohort studies, or low-quality randomized controlled trials). No evidence clearly links PPIs to gastric cancer or carcinoid, enteric infections, or significant nutrient malabsorption

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)

Should you evaluate for CAD in seniors with premature ventricular contractions?

Current guidelines suggest evaluating patients with premature ventricular contractions (PVCs) and associated risk factors for underlying coronary artery disease (strength of recommendation [SOR]: C, expert opinion)

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