Evidence-based Answers Research Articles

Does the administration of loop diuretics at the time of blood transfusion prevent transfusion-associated circulatory overload (TACO)?

EVIDENCE-BASED ANSWER The answer is unknown. In patients identified with TACO, 90% had received loop diuretics before, during, or after receiving blood components. However, mortality was higher in patients receiving diuretics before transfusion than during or after transfusion (SOR: B, longitudinal study with cohort analysis). In preterm infants, furosemide given before packed red blood cell (PRBC) transfusion decreases mean FiO2 compared with baseline (SOR: C, systematic review of RCTs with disease-oriented evidence).

Are amphetamines helpful for adults with ADHD?

EVIDENCE-BASED ANSWER Amphetamine medications lead to large improvements in symptom severity in adults with attention deficit hyperactivity disorder (ADHD) over the short term; however, patients given amphetamines are more likely to stop treatment due to adverse events. Long-term efficacy has not been established (SOR: A, meta-analyses of RCTs).

What are the risks and benefits of intrauterine device (IUD) insertion on the same day as office counseling?

EVIDENCE-BASED ANSWER Risk of pelvic inflammatory disease (PID) does not differ between same-day or delayed insertion for women without overt cervicitis (SOR: A, meta-analysis of RCTs and prospective cohort). Same-day insertion increases probability of continued IUD use compared with delayed insertion. However, women with same-day insertion after an induced or spontaneous abortion are more than twice as likely to have IUD expulsion than women with delayed insertion (SOR: A, meta-analysis of RCTs). Return rates for a subsequent appointment for IUD insertion are as low as 54% (SOR: B, cross-sectional study). Delaying IUD placement for sexually transmitted disease testing is discouraged in asymptomatic patients (SOR: C, consensus opinion).

How do you identify patients with nonalcoholic fatty liver disease who have progressed to nonalcoholic steatohepatitis?

EVIDENCE-BASED ANSWER Ultrasound is useful for finding patients with high degrees of steatosis at risk for nonalcoholic steatohepatitis (NASH), but is less useful for finding nonalcoholic fatty liver disease (NAFLD) if steatosis involves less than 30% of the liver. Magnetic resonance imaging (MRI) performs better than ultrasound if steatosis is less than 25% but more than 10%. Alanine transaminase (ALT) levels are poor predictors of the presence of NASH (SOR: C, systematic review of RCTs and observational studies and metaanalysis of diagnostic cohort studies). After excluding other causes of liver disease, the NAFLD Fibrosis Score is useful for determining which patients may need a biopsy to evaluate for NASH (SOR: C, expert opinion).

Tools of the trade: Improving nurses' ability to access and evaluate research.

To evaluate the effect of a manager-required RN competency on staff nurses' perceived knowledge, ability and frequency of information-seeking activities. Basing clinical practice on research and standards of care is essential to delivering appropriate care with optimal outcomes. Nurses' information-seeking abilities are critical for acquiring evidence-based answers to aid clinical decision-making, yet nurses under-utilize library resources and report barriers. A unit manager sought to test the effect of an innovative competency for acquiring and appraising evidence for practice. This longitudinal descriptive study evaluated 28 nurses before and after a 1-hr class, as well as 5months later. The class covered library information services and the basics of critiquing research articles. Nurses had statistically significant improvements in four of five items measuring knowledge/ability and four of five items measuring frequency of information-seeking activities. At 5months, most knowledge/ability items increased. There was no effect of nurse characteristics on outcomes. A required competency improved nurses' knowledge, ability and frequency of acquiring and appraising evidence with a single 1-hr class and a hands-on practice activity. Unit managers can have great impact on nurses' use of evidence for practice.

Can ESR and CRP be used interchangeably in the management of rheumatoid arthritis?

EVIDENCE-BASED ANSWER Yes. Erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) have a concordance of 69% in patients with rheumatoid arthritis (RA). The measures are nearly equal in predicting swollen joint count but both are poorly correlated with clinical disease activity (SOR: A, metaanalysis of RCTs). Evidence is conflicting about whether ESR and CRP can predict radiographic progression of RA (SOR: C, disease-oriented data from systematic review of conflicting RCTs and cohort studies).

What is the prevalence of vitamin D deficiency in the United States?

EVIDENCE-BASED ANSWER The overall prevalence of vitamin D deficiency (25-hydroxyvitamin D levels <30 nmol/L) in the United States is 8.1% and is slightly higher in females (9.9%) than males (6.3%). Mexican Americans (11%), and non-Hispanic blacks (31%) have a higher prevalence than whites (3.6%). In adolescents, the prevalence is 8.5% to 24.1% using 30 to 37.5 nmol/L cutoffs. Breastfed infants not receiving vitamin supplements have a prevalence of 64%. The data on children are inconsistent, with rates ranging from 0.7% to 40% (SOR: C, cross-sectional studies of diseaseoriented data).

Is valproate use during pregnancy associated with an increased risk of developmental delays in childhood?

EVIDENCE-BASED ANSWER Yes, depending on dose. Compared with untreated controls, carbamazepine, lamotrigine, levetiracetam, and phenytoin, higher doses of valproate (≥800 mg/d) are associated with lower IQ scores at age 6 and delays in cognitive development at age 2 (SOR: B, based on prospective cohort studies).

In patients with significant acute muscle strain, is heat or cold more effective for reducing symptoms?

EVIDENCE-BASED ANSWER Either heat and cold therapy applied for 30 minutes combined with ibuprofen provides mild yet similar immediate relief of acute back or neck strains (SOR: C, small RCT). Heat and cold are equivalent in the treatment of acute and chronic low back pain (SOR: B, nonrandomized trial).

Is sleep-disordered-breathing associated with poor maternal-fetal outcomes?

EVIDENCE-BASED ANSWER Moderate-to-severe sleep-disordered-breathing (SDB) in pregnant women is associated with various maternal and fetal morbidities: gestational diabetes mellitus, pregnancy-related hypertension, preterm delivery, intrauterine growth restriction, low birth weight, and neonatal intensive care unit (NICU) admission (SOR: B, meta-analysis of limited-quality observational studies). Limited evidence suggests a positive SDB screen with the Berlin Questionnaire is associated with hypertensive disorders of pregnancy (SOR: B, cohort study).

What is the best treatment for seizures in patients with hyponatremia?

EVIDENCE-BASED ANSWER In the setting of severe hyponatremia symptoms, including seizure, the best treatment is an infusion of 3% hypertonic saline until symptoms resolve (SOR: B, based on systematic review of consensus practice guidelines). The rate and volume recommended varies, ranging from continuous infusion to bolus doses, but correction should not exceed 10 mmol/L in the first 24 hours (SOR C, based on consensus guidelines).

Does omega-3 supplementation reduce cardiac mortality?

EVIDENCE-BASED ANSWER No. Omega-3 fatty acid supplementation does not reduce cardiac mortality in primary or secondary prevention (SOR: A, meta-analysis of RCTs and 2 RCTs).

For female athletes, what sports are at high risk for concussion?

EVIDENCE-BASED ANSWER Sports with the highest risk of concussion in female high school athletes are soccer and lacrosse with about 0.35 concussions for every 1,000 athletes participating in 1 game. In college sports, ice hockey has the highest risk at nearly 1 concussion for every 1,000 athletes participating in 1 game, followed by soccer (SOR: B, descriptive epidemiologic studies).

Contraception in general practice: Frequently asked questions

The aim of this article is to address questions frequently asked by practice nurses related to contraception and, in particular, combined hormonal contraception. The questions are based on an analysis of enquiries and clinical situations highlighted during contraception and sexual health training programmes for practice nurses. To formulate evidence-based answers, electronic sources were routinely searched, including clinical guidance from the Faculty of Sexual and Reproductive Health; the World Health Organization publications: UK Medical Eligibility Recommendations for Contraceptive Use; the Cochrane library; and MEDLINE, plus manufacturers' summaries of product characteristics.

Volume of Anesthetic Agents and IANB Success: A Systematic Review.

The aim of this study was to provide an evidence-based answer to the question: "Is 3.6-mL volume of an anesthetic agent more effective than 1.8-mL volume in providing anesthesia for mandibular molars?" Following formulation of research question and keyword selection, a comprehensive search of the following databases was conducted: Cochrane library, PubMed, Scopus, Google Scholar, ProQuest, and Clinicaltrials.gov. Three-phase eligibility appraisal and quality assessment of the studies were carried out by 2 independent reviewers. To reduce clinical heterogeneity, the included studies were divided into 2 groups: studies on healthy teeth and studies on teeth with pulpitis. The data of included studies were statistically combined through meta-analysis using a fixed-effects model. A total of 20,778 records were initially retrieved from the search. Following screening and eligibility assessment, 8 studies met the eligibility criteria and were included for qualitative synthesis. Of those, 5 studies were qualified for meta-analysis. In the irreversible pulpitis group, increasing the volume of anesthetic agent from 1.8 to 3.6 mL significantly increased the success rate of inferior alveolar nerve block (risk ratio = 2.45, 95% CI: 1.67-3.59, p < .001). However, there was insufficient evidence to draw a conclusion regarding healthy teeth.

Why Judaism and Islam Prohibit Eating Pork and Consuming Blood as a Food?

To date, many influential religious leaders from both Judaism and Islam have attempted to provide answers to the question of why both these religions prohibit eating pork. The most straightforward answer is that the Lord has prohibited the eating of pork and all unclean meat, including unclean fish, birds, mammals and other creatures. Followers of Judaism and Islam, respectively, must eat only kosher or halal food. Prohibitions on eating unclean food are written in the Torah and in the Koran: “He hath only forbidden you dead meat, and blood, and the flesh of swine, and that on which any other name hath been invoked besides that of Allah. For Allah is Oft-forgiving Most Merciful” (Surah the Cow 2: 173), and “He has only forbidden you dead meat, and blood, and the flesh of swine, and any (food) over which the name of other than Allah has been invoked. For Allah is Oft-Forgiving, Most Merciful” (Surah the Bee 16: 115). In principle, the laws governing kosher food in the Torah are the similar. Their traditional prohibition on eating pork and unclean food has often been used as an excuse to spark hatred of Jews and Muslims. In this paper, we attempt to study the possible sources of the prohibition to provide evidence-based answers as to why the prohibition exists, and to counter the xenophobic misrepresentations and slurs on these subjects. As it is not possible to cover all aspects of kosher and halal food in a short paper, we focus on examining the prohibition on Jews and Muslims on eating pork, human flesh and blood from all sources and, particularly, using the blood of mammals in the preparation of food.

What is the most effective nonsurgical medical treatment for adults with mild to moderate ulcerative colitis?

EVIDENCE-BASED ANSWER Oral 5-aminosalicylic acid (5-ASA) formulations such as mesalamine produce similar remission rates as oral sulfasalazine (SASP) with fewer side effects (SOR: A, meta-analysis of RCTs). Mesalamine enemas are more effective than budesonide enemas with fewer side effects (SOR: B, single RCT). Combination therapy with rectal and oral mesalamine is more effective than oral mesalamine alone (SOR: B, single RCT).

Does daily caffeine intake increase the risk of anxiety?

EVIDENCE-BASED ANSWER Caffeine increases self-rated anxiety more than placebo, but the dose-response relationship is inconsistent (SOR: B, 2 small RCTs). This effect may be exclusive to men (SOR: C, small RCT). Patients with generalized anxiety disorder are more sensitive to the anxiogenic effects of caffeine than patients with panic disorder or no psychiatric illness (SOR: B, small RCT).

Toothbrushing–Should We Advise Mechanical or Power Brushes? Results of an International Delphi Conference

To develop evidence-based answers to a series of questions in relation to toothbrushing using a modified Delphi consensus approach. Oral hygiene and especially toothbrushing have been a fundamental part of the efforts to prevent caries and gingivitis. The questions discussed involved the frequency and duration of brushing, the effectiveness and safety of powered brushes and the recommendations for children and orthodontic patients. The Delphi panel agreed that twice daily brushing for 2 minutes and a systematic pattern is advised. Moreover, it was concluded that evidence suggests that power brushes are safe and more effective in the short and long-term compared to manual brushes in terms of plaque removal and gingivitis reduction. For children and orthodontic patients, the likelihood of enhancing compliance/convenience with use of a power brush was highlighted. Toothbrushing constitutes a fundamental part of the efforts to prevent caries and gingivitis. Twice daily brushing for 2 minutes and a systematic pattern is advised. Power brushes are safe and could provide benefits, for adults, children and orthodontic patients.

What are the benefits of folate consumption during pregnancy?

EVIDENCE-BASED ANSWER Maternal folic acid supplementation taken from before conception through the first trimester reduces primary and recurrent neural tube defects (NTDs) by more than 65%. Folic acid supplementation during pregnancy decreases maternal megaloblastic anemia at the time of delivery by about 80%. Folic acid supplementation does not reduce rates of cleft palate, cleft lip, congenital heart defects, miscarriage, preterm delivery, or stillbirth, or affect mean birthweight (SOR: A, meta-analyses of RCTs).