Evidence-based Answers Research Articles

Glycemic Control of Surgical Patients. What is Correct, What is Not

Perioperative hyperglycemia is very common among critically ill patients with or without diabetes mellitus (DM). Perioperative elevated levels of blood glucose (BG) have been linked with increases in morbidity, infections, anastomotic failure, autoimmune dysfunction, and raised mortality and prolongation of hospitalization. A variety of different approaches have been taken for the control of BG in the perioperative period, and different methods of measurement have been proposed, among which, point of care (POC) meters, arterial blood gas analysis and venous plasma analysis prevail. The aim of this literature review was to provide evidence-based answers as to how BG levels should be monitored. We conclude that more conservative glycemic control is preferable to “tight glycemic control” (TGC), in order to avoid complications associated with episodes of hypoglycemia.

Surgery of the pancreatic cystic echinococcosis: systematic review.

The prevalence of pancreatic cystic echinococcosis (PCE) in the world is low ranging between 0.2% and 0.6%. The diagnosis of PCE is easy when it is associated to other location such as liver, it became difficult when PCE was isolated simulating other diagnosis such as pseudocyst, a choledochal cyst, serous or mucinous cystadenoma and cystadenocarcinoma. This systematic review aimed to provide evidence-based answer to the following questions: (I) what are the efficient tools to affirm the diagnosis of isolated PCE and (II) what are the best therapeutic strategy for the PCE? An electronic search was performed by two authors (W Dougaz, I Bouasker). Medline, Scopus, Embase, Web of Science, Google Scholar and Cochrane collaboration were consulted. The keywords used were "cyst", "echinococcosis", "hydatid cyst" and "pancreas". All abstracts were analyzed followed by extraction of the full text by the same two authors (W Dougaz, I Bouasker), all divergences were resolved by discussion with C Dziri. Recommendations were based on Oxford's classification: (I) what are the efficient tools to affirm the diagnosis of PCE? -ultrasound remains the cornerstone of diagnosis. Magnetic resonance imaging (MRI) reproduces the ultrasound defined features of CE better than computed tomography (CT). MRI with heavily T2-weighted series is preferable to CT. Pancreatic duct MRI should be promising to identify a fistula between PCE and pancreatic duct (level of evidence 3-recommendation B); (II) what are the best therapeutic strategy for the PCE? -surgery is the main treatment of PCE. Open approach is validated. The decision depends of the location of PCE: head versus body and/or tail of the pancreas (level of evidence 5-recommendation D): for the head of the pancreas, the tendency is toward conservative surgery. For body and/or tail of the pancreas, the tendency is toward radical surgery. Medical treatment (albendazole) should be prescribed 1 week before surgery and 2 months during postoperative period (level II evidence and grade C recommendation).

In pregnant women who travel, does use of compression stockings reduce risk of deep venous thrombosis (DVT)?

EVIDENCE-BASED ANSWER Perhaps. Among nonpregnant patients with varying risks of DVT (SOR: B, meta-analyses of RCTs) and large cohorts that included pregnant patients (SOR:C, meta-analysis not limited to RCTs), treating about 29 air travelers with compression stockings prevents 1 DVT. Pregnant air travelers should take precautions to minimize risk of venous thromboembolism, including use of support stockings, periodic movement of the lower extremities, avoiding restrictive clothing, occasional ambulation, and maintenance of adequate hydration (SOR: C, expert opinion).

Are topical NSAIDs effective in decreasing pain from acute musculoskeletal injuries?

EVIDENCE-BASED ANSWER Yes. Topical NSAIDs are up to 60% more likely to reduce pain from acute musculoskeletal injuries by 50% at day 7 than placebo (SOR: A, meta-analysis of RCTs). Topical salicylates are nearly twice as likely to decrease pain scores by 50% at day 7 compared with placebo, but may have increased systemic and local adverse reactions (SOR: B, meta-analysis of poor quality RCTs).

What is the relationship between anorexia nervosa and miscarriage?

EVIDENCE-BASED ANSWER Although miscarriage may be associated with binge eating disorder and atypical bulimia nervosa, no association is apparent between anorexia nervosa and miscarriage (SOR: B, retrospective case-control study and cohort study).

In overweight or obese adults, does increased daily fiber intake result in more weight reduction compared to routine fiber intake?

EVIDENCE-BASED ANSWER Probably not. A bean-based high fiber is not superior to a low-carbohydrate diet for weight loss (SOR: C, conflicting RCTs). Fiber goals may be easier to reach with a beanbased diet than a fruit, vegetable, and grain-based diet (SOR: C, small RCT).

Is clopidogrel plus aspirin superior to aspirin alone for primary prevention of cardiovascular outcomes among patients with multiple risk factors?

EVIDENCE-BASED ANSWER No, clopidogrel plus aspirin (ASA) is not better than ASA alone for primary prevention of cardiovascular outcomes among patients with multiple risk factors, and this combination therapy increases the risk of bleeding (SOR: B, RCT). ASA alone is recommended for primary prevention in patients aged 50 to 59 years old with a 10-year risk of cardiovascular disease (CVD) of 10% or more and a low bleeding risk; ASA is recommended selectively in patients 60 to 69 years old (SOR: C, expert opinion).

Is an isolated elevation of maternal human chorionic gonadotropin (hCG) associated with adverse fetal outcomes?

EVIDENCE-BASED ANSWER An isolated elevation in hCG is associated with an increased risk of preterm birth and fetal death (SOR: C, inconsistent case-control studies). Elevated hCG is not associated with increased risk of intrauterine growth restriction (IUGR), small-for-gestational-age (SGA) infants, low Apgar scores, or early preterm birth (SOR: C, consistent case-control studies). Among women with preeclampsia and elevated hCG, there is an increased risk of preterm birth, low birth weight, and newborn intensive care unit (NICU) admission (SOR: C, casecontrol study).

What is the best treatment for erectile dysfunction in men with diabetes mellitus?

EVIDENCE-BASED ANSWER Phosphodiesterase type 5 (PDE-5) inhibitor therapy is superior to placebo for erectile dysfunction (ED) in patients with and without diabetes. No studies directly compare PDE-5 inhibitors (SOR: A, systematic review and RCT). Testosterone treatment may improve sexual function in patients with diabetes and severe hypogonadism (SOR: C, single RCT).

What are the success rates for CPR for cardiac arrest in the community with and without rescue breathing?

EVIDENCE-BASED ANSWER For untrained bystanders instructed by a dispatcher, compression-only cardiopulmonary resuscitation (COCPR) in adults improves survival to hospital discharge by 20% compared with cardiopulmonary resuscitation with rescue breathing (standard CPR). However, both techniques are associated with similar success if bystanders are not receiving dispatcher instruction (SOR: A, meta-analysis of RCTs). Standard CPR is associated with slightly higher 1-month survival rate than COCRP in mixed populations of children and adults (SOR: B, metaanalysis of cohort studies and single cohort study). CPR providers with prior CPR training should continue doing standard CPR, but lay providers instructed by dispatchers should do COCPR (SOR: C, expert opinion).

What nonnarcotic oral analgesics are the safe for patients taking warfarin?

EVIDENCE-BASED ANSWER The answer is not entirely clear. COX-2 inhibitors appear safer than nonselective nonsteroidal anti-inflammatory drugs (NSAIDs) for patients taking warfarin (SOR: B, cohort and case-control studies). Acetaminophen increases the international normalized ratio (INR) in patients taking warfarin by 0.67 to 0.83 over placebo, but with unclear clinical effect (SOR: C, small RCTs with disease-oriented outcomes).

How well does C-reactive protein correlate with disease progression in rheumatoid arthritis?

EVIDENCE-BASED ANSWER In patients with rheumatoid arthritis (RA), C-reactive protein (CRP) levels moderately correlate with radiographic disease progression at 10 years, while radiographic progression at 1 year is associated with a rise in CRP levels (SOR: C, case series and retrospective cohort study). Persistently elevated CRP levels may be useful in predicting need for joint replacement surgery (SOR: C, retrospective cohort study).

Is vision testing effective in preventing driving fatalities in older adults?

EVIDENCE-BASED ANSWER US state driver's license policies that include vision testing for older adults are associated with a 2% to 8% lower risk of fatal automobile accidents (SOR: C, secondary analyses of a cross-sectional administrative database).

What is the optimal education structure for improving diabetes control and minimizing distress in patients with type 2 diabetes?

EVIDENCE-BASED ANSWER Group-based and individual-based diabetes education reduces glycosylated hemoglobin (HbA1C) slightly more than routine provider visits, with greater effect seen in patients with higher baseline HbA1C (SOR: C, meta-analyses of RCTs and single cohort study with disease-oriented evidence). The differences in HbA1C between individual and group education at 6 months are inconsistent, but no difference is apparent after 12 months (SOR: C, inconsistent meta-analysis of RCTs and single RCT with disease-oriented outcomes). Less time-intensive individual sessions monthly are slightly better than more time-intensive group sessions weekly at reducing HbA1C and diabetes-related distress (SOR: B, RCT).

In pregnant women, do docosahexaenoic acid (DHA) supplements lead to any differences in early childhood developmental outcomes?

EVIDENCE-BASED ANSWER DHA supplementation in pregnant women does not appear to lead to any consistent differences in early childhood cognitive, motor, or language development (SOR: B, RCTs with conflicting results).

What are the diagnostic criteria for interstitial cystitis?

EVIDENCE-BASED ANSWER Interstitial cystitis may be diagnosed by the more restrictive criteria of the National Institute of Diabetes, Digestive, and Kidney (NIDDK), which requires bladder pain or urinary urgency for 9 months, the presence of glomerulations or Hunner's ulcer on cystoscopy, and urodynamic evaluation. The NIDDK criteria exclude more than 50% of patients who clinicians suspect have interstitial cystitis based on the more inclusive criteria of urinary frequency (≥7 times per day), urgency, or bladder pain for at least 6 months with no other clear etiologies (SOR: B, cross-sectional study). The most common symptoms of interstitial cystitis include urgency, frequency, nocturia, pain in the bladder, pain in the urethra, and pain in the vagina (SOR: B, systematic review of cross-sectional studies). Experts characterize interstitial cystitis as an unpleasant sensation (pain, pressure, discomfort) thought to be related to the urinary bladder and associated with lower urinary tract symptoms of more than 6 weeks’ duration, in the absence of infection or other identifiable causes (SOR: C, expert opinion).

Is methotrexate effective in maintaining remission in Crohn's disease?

EVIDENCE-BASED ANSWER Methotrexate (MTX) may be effective for maintaining remission in patients with moderately severe Crohn's disease compared with placebo (SOR: B, systematic reviews of heterogeneous RCTs).

What is the clinical significance of a small pericardial effusion incidentally discovered on CT or echocardiogram?

EVIDENCE-BASED ANSWER The presence of a small asymptomatic pericardial effusion is associated with a 20% increase in mortality at 1 year and is more common in patients with heart failure with reduced ejection fraction, diabetes mellitus, renal disease, and malignancy. Most (94%) effusions resolve or remain unchanged by 1-year follow-up evaluation (SOR: B, retrospective cohort study). Followup evaluation of a pericardial effusion should be based primarily on the size of the effusion, symptoms, and other clinical features such as known associated disease or inflammatory markers. Idiopathic effusions of less than 1 cm generally do not need follow-up (SOR: C, expert opinion).

What is the effectiveness and safety of serial intraarticular steroid injections of the knee?

EVIDENCE-BASED ANSWER In patients with osteoarthritis of the knee, serial intraarticular (IA) corticosteroid injections given every 3 months do not cause radiographic joint space narrowing at 2 years (SOR: B, single RCT). When single and serial injections are pooled, pain and function is improved in the short term (up to 6 weeks) but not the long term (after 13 weeks) (SOR: A, meta-analysis of RCTs). Single injections maintain symptom improvement up to 24 weeks (SOR: A, meta-analysis of RCTs).

How accurate are patient-collected vaginal gonorrhea and chlamydia swabs in detecting infection?

EVIDENCE-BASED ANSWER Patient-collected vaginal swabs are accurate—with a sensitivity of 92% and a specificity of 98% for chlamydia and a sensitivity of 98% and a specificity of 97% for gonorrhea, when using provider-collected endocervical swabs as the gold standard (SOR: B, meta-analysis of cross-sectional studies).