Evidence-based Answers Research Articles

Does vaginal douching cause bacterial vaginosis?

EVIDENCE-BASED ANSWER Vaginal douching is associated with a 20% higher incidence of bacterial vaginosis, although causation remains unclear (SOR: B, cohort studies with consistent findings). Cessation of douching for 4 weeks does not decrease the risk of bacterial vaginosis (SOR: C, small cohort study).

Is ferric carboxy maltose more effective than iron sucrose for the treatment of iron deficiency anemia in patients with chronic kidney disease (CKD)?

EVIDENCE-BASED ANSWER Ferric carboxy maltose is at least as effective as iron sucrose in increasing hemoglobin levels in patients with iron deficiency anemia who have CKD. Ferric carboxy maltose and iron sucrose are both more effective than oral iron supplementation in increasing hemoglobin levels (SOR: C, RCTs of disease-oriented outcomes).

Do Southeast Asian immigrants have a higher incidence of cervical cancer than the general population of Western countries?

EVIDENCE-BASED ANSWER The incidence rates of cervical cancer in Southeast Asian immigrants in the United States are higher than that of non-Hispanic whites in the United States, but they appear to be decreasing. Among Southeast Asian immigrants in the United States, the incidence rates are highest in the Laotian population, followed by Vietnamese and Filipina populations (SOR: C, 2 cross-sectional studies).

What is the best treatment for chronic anal fissures in adults?

EVIDENCE-BASED ANSWER For medical treatments, topical nitroglycerin, topical calcium channel blockers, and botulinum toxin injections are effective in about half of patients but nitroglycerin has more adverse effects than the other agents and has a high recurrence rate in chronic anal fissure. Lateral internal sphincterotomy results in long-term cure rates of more than 90% and less than a 5% risk of incontinence (SOR: A, meta-analyses of RCTs). Medical therapies are usually recommended first, but lateral internal sphincterotomy is the treatment of choice for refractory anal fissures (SOR: C, expert opinion).

What is the best treatment for plantar warts?

EVIDENCE-BASED ANSWER Topical salicylic or lactic acid leads to slightly higher clinical cure rates (66% vs 50%) compared with placebo/no treatment for the treatment of plantar warts (SOR: A, meta-analysis of RCTs) and is recommended first-line treatment (SOR: C, expert opinion). Cryotherapy and placebo both have a 25% cure rate (SOR: B, RCT), yet cryotherapy is also recommended as first-line treatment of plantar warts (SOR: C, expert opinion). Combining salicylic acid and cryotherapy does not improve cure rates (SOR: A, meta-analysis of RCTs). Alternative interventions include laser, topical 5-fluorouracil, topical immunotherapy, hyperthermia, dithranol, formaldehyde, glutaraldehyde, photodynamic therapy, and podophyllotoxin (SOR: C, expert opinion).

Is vaginal estrogen safe in patients with a history of venous thromboembolism caused by estrogen?

EVIDENCE-BASED ANSWER Vaginal estrogen medications do not appear to increase risk of recurrent venous thromboembolism (VTE) in patients with a history of estrogen-related VTE when used in low doses (SOR: C, case-control study and consensus guidelines).

Are neonatal mortality rates increased in stand-alone birthing center births compared with hospital births?

EVIDENCE-BASED ANSWER Neonatal mortality rates do not differ when low-risk patients deliver in an alternative birthing setting within a hospital or in a stand-alone birthing center compared with a hospital-based obstetric unit (SOR: B, meta-analysis of RCT and quasi-RCTs and 2 cohort studies). However, when home births are grouped with stand-alone birthing centers there is an associated increase of 1.5 perinatal deaths per 1,000 deliveries (SOR: B, cohort study).

Does alcohol consumption affect blood pressure?

EVIDENCE-BASED ANSWER Alcohol reduction efforts result in only a small decrease (average 3 mmHg systolic and 2 mmHg diastolic) in blood pressure (SOR: A, systematic review of RCTs.) However, moderate to heavy alcohol consumption is associated with an increased risk of hypertension (SOR: B, metaanalysis of cohort studies).

Continue, adjust, or stop antipsychotic medication: developing and user testing an encounter decision aid for people with first-episode and long-term psychosis

BackgroundPeople with psychosis struggle with decisions about their use of antipsychotics. They often want to reduce the dose or stop, while facing uncertainty regarding the effects these decisions will have on their treatment and recovery. They may also fear raising this issue with clinicians. The purpose of this study was to develop and test a shared decision making (SDM) tool to support patients and clinicians in making decisions about antipsychotics.MethodsA diverse editorial research team developed an Encounter Decision Aid (EDA) for patients and clinicians to use as part of the psychiatric consultation. The EDA was tested using 24 semistructured interviews with participants representing six stakeholder groups: patients with first-episode psychosis, patients with long-term psychosis, family members, psychiatrists, mental health counselors, and administrators. We used inductive and deductive coding of interview transcripts to identify points to revise within three domains: general impression and purpose of the EDA; suggested changes to the content, wording, and appearance; and usability and potential contribution to the psychiatric consultation.ResultsAn EDA was developed in an iterative process that yielded evidence-based answers to five frequently asked questions about antipsychotic medications. Patients with long-term psychosis and mental health counselors suggested more changes and revisions than patients with first-episode psychosis and psychiatrists. Family members suggested more revisions to the answers about potential risks of stopping or adjusting antipsychotics than other respondents.ConclusionsThe EDA was perceived as potentially useful and feasible in psychiatric routine care, especially if presented during the consultation.

In women with dense breast tissue, does the addition of automated whole-breast ultrasound to mammography lead to increased invasive testing?

EVIDENCE-BASED ANSWER In women with dense breasts, the addition of automated whole-breast ultrasound (ABUS) improves cancer detection rates but increases false-positive results, leading to more biopsies and surgeries (SOR: C, cohort study and validation study).

Does acupuncture decrease the frequency of tension headaches?

EVIDENCE-BASED ANSWER Yes. For tension headaches, acupuncture leads to about a 30% higher overall response rate, slightly more patients achieving a 50% reduction in the frequency of tension headaches, and about 2 fewer headaches days per month compared with sham procedures (SOR: A, meta-analyses of RCTs).

In hospitalized patients with communityacquired pneumonia, do corticosteroids improve outcomes?

EVIDENCE-BASED ANSWER Yes. Corticosteroids in hospitalized patients with community-acquired pneumonia decrease the length of non-intensive care unit hospital stays by 1 day, time to clinical stability by 1 day, need for mechanical ventilation by 55%, and progression to acute respiratory distress syndrome (ARDS) by 76%. Corticosteroids decrease mortality in cases of severe community-acquired pneumonia (SOR: A, meta-analyses of RCTs).

Which is better for preventing injuries: forefoot strike or rearfoot strike running?

EVIDENCE-BASED ANSWER They are likely about the same. Neither form of running consistently prevents injuries (SOR: B, retrospective and survey studies).

Does external cephalic version for breech presentation performed prior to an estimated gestational age of 37 weeks offer any benefits or pose any risks compared with external cephalic version performed at term?

EVIDENCE-BASED ANSWER Compared with term external cephalic version, preterm (<37 weeks' gestation) external cephalic version decreases the rate of noncephalic presentation at birth by 19% and the rate of vaginal breech birth by 56%, but increases the risk of late preterm birth by 50% (SOR: A, systematic review of RCTs). The 2016 American College of Obstetrician and Gynecologists guidelines for the management of external cephalic version recommend offering the procedure near term. In comparison, the 2010 guidelines from the Royal College of Obstetricians and Gynaecologists recommend external cephalic version at 36 weeks for nulligravidas and 37 weeks for multigravidas (SOR: C, systematic guidelines).

How effective are antibiotics compared with placebo for the treatment of acute maxillary sinusitis in adults?

EVIDENCE-BASED ANSWER Antibiotics are slightly better than placebo in the short term with an absolute difference of 5% to 11% in patients improved or cured by 7 to 15 days. No difference is noted at 16 to 60 days or in relapse after 60 days. The modest improvement in outcomes may be offset by the increased risk of adverse effects (SOR: A, 2 meta-analyses of RCTs).

Does osteoporosis screening in postmenopausal women prevent fractures?

EVIDENCE-BASED ANSWER The effect of osteoporosis screening in postmenopausal women is unclear. In a mixed population of pre- and postmenopausal women, osteoporosis screening increases the use of medications to treat osteoporosis and slightly decreases all fractures by an absolute difference of 0.6%, but does not decrease osteoporotic fractures of the hip, lumbar spine, femur, or wrist (SOR: B, RCT). In a mixed male and female population 65 years of age and older, screening is associated with 3.4 fewer hip fractures per 1,000 patients (SOR: B, cohort trial). Screening for osteoporosis is recommended in women 65 years and older, and younger women with similar risk to a white woman 65 years of age without other risk factors (SOR: B, evidence-informed guidelines).

Is levetiracetam more effective than carbamazepine for the long-term treatment of generalized tonic-clonic seizures in healthy adults?

EVIDENCE-BASED ANSWER Levetiracetam is as effective, but not more effective, than carbamazepine for monotherapy in patients with newly diagnosed focal or generalized epilepsy followed for up to 12 months. Similarly, the withdrawal rates for adverse events are not significantly different between the 2 treatments (SOR: A, 2 consistent RCTs).

What is the best collection method to diagnose chlamydia infection in women?

EVIDENCE-BASED ANSWER Nucleic acid amplification testing (NAAT) using selfcollected vaginal swabs is consistently more sensitive than using first-voided urine, but inconsistently more sensitive than using provider-collected endocervical swabs in women with or without symptoms (SOR: B, 3 multicenter, diagnostic cohort studies).

The Challenges of First-in-Human Stem Cell Clinical Trials: What Does This Mean for Ethics and Institutional Review Boards?

Stem cell-based clinical interventions are increasingly advancing through preclinical testing and approaching clinical trials. The complexity and diversity of these approaches, and the confusion created by unproven and untested stem cell-based “therapies,” create a growing need for a more comprehensive review of these early-stage human trials to ensure they place the patients at minimal risk of adverse events but are also based on solid evidence of preclinical efficacy with a clear scientific rationale for that effect. To address this issue and supplement the independent review process, especially that of the ethics and institutional review boards who may not be experts in stem cell biology, the International Society for Stem Cell Research (ISSCR) has developed a set of practical questions to cover the major issues for which clear evidence-based answers need to be obtained before approving a stem cell-based trial.

Is white coat hypertension associated with increased cardiovascular risk?

EVIDENCE-BASED ANSWER White coat hypertension is associated with higher rates of cardiovascular disease morbidity and mortality compared with a normal blood pressure (BP), but is not associated with increased all-cause mortality and stroke risk (SOR: A, meta-analysis of cohort studies and cohort study). This finding does not indicate, however, that treating white coat hypertension medically has a reasonable risk-benefit profile.