1. Fact vs Fictions Evidence Based Medicine-? A Moving Target The Newest Trends=Evidence Pearls of Practice 2012

2. Objectives: At the end of this program you should be better able to: Recognize more of what is currently recommended in various areas of patient care-realize “best practices” can change rapidly- that the MD must keep up as difficult as that may be. Appreciate best recommendations come from unbiased met analysis-many studies of the same subject-not a single paper. Recognize the need to communicate to patients the scope of what is currently advised as “best practice”, (give the pros and cons). Buy a good lunch, after getting a free breakfast

3. Disclosure I do not have any significant financial disclosures to disclose.

4. Pre-Test Questions True or False: Use of lipid lowering drugs in adults with normal lipids as a preventative measure, and in children, is a good idea. True or False: Peanut butter applied to the back can be associated with relief of pain 90% of the time over 3-6 months. True or False: Bed rest of a week or more is required for fastest improvement of acute back pain. True of False: Ambien or similar sedative is the best treatment for insomnia in the elderly. True or False: Ankle edema associated with a sprain, medicine wise, is best treated with a Motrin, Voltaren or Celebrex. True or False: Steroid joint injections should always be done with ultrasound guidance. True or False: All diabetics should be treated to a Hgaic level of 7%. True or False: These questions are stupid.

5. Facts vs. Fictions Evidence Based Medicine-? A Moving Target The Newest Trends in=Evidence Patient Satisfaction surveys-new standard to evaluate health care businesses and doctors. Most satisfied patients had 12% more admissions, 9% more health care expenditures and used more drugs, and 26% higher mortality than less satisfied patients.

6. Obesity in infants/children: More in formular feed than breast feed and more if given solids before age 4 months.

7. C-Sections Increasing but the indications for these are not. Convenience factor?

8. Lactobacillus Rueters 5 drops of Lactobacillus Rueters given AM before feeding decreases colic episodes by 41%

9. Lactobacillus Acidophilus Lactobacillus Acidophilus given daily age 3-5 years cut fever and cough episodes by 50% and antibiotic use by 66%.

10. Lipid Lowering Drugs Use of lipid (LDL) lowering drugs in children as proposed by the American Academy of Pediatrics 3 years ago not felt appropriate- few get to suggested goal and cost and side effects of meds significant-no evidence so far is associated with better health cardiovascular wise.

11. Treating Lipids Treating lipids in patients as a preventative measure-patient with no evidence of risks or of heart disease does not decrease mortality- diet and exercise do.

12. HDL Increasing HDL with niacin has no effect on mortality of patients with heart disease.

13. Treating Lipids with Fibrates Treating lipids with fibrates (lopid and tricor) to lower triglycerides does not lower the risk of cardiovascular disease as studied over 8 years.

14. Statins Statin use may increase risk of diabetes-in addition to risk of myopathy and liver enzyme increases and use in patient with no heart disease suggested not appropriate.

15. Cognitive Behavior Therapy Cognitive Behavior Therapy=teaching patients with recent heart attack to think good thoughts and positive thoughts and exercise to tolerance-done in 20 sessions of 2 hours over 8 years cuts rate of recurrent heart attack to one in 3 compared to one in 2 in the usual care group in a published article.

16. NSAID NSAID use increases risk of death or new heart attack in patients with prior heart attack by 50%. Felt to increase risk of CVA or heart attack in all past age 65.

17. Defibrillators 20% of implanted cardiac defibrillators felt not indicated-not advised used within 40 days of an infarct or during recovery from CABG or in patient with class 4 heart failure-may increase risk of death in these circumstances.

18. Back-Ache Pain X-ray of lower back in patient with acute back ache-unless associated with severe trauma or fever or weight loss or night pain no help. MRI or CT myelogram best if surgery is being considered after 6-12 weeks. Only 5-10% of low back pain persists after 6 months even if no treatment given.

19. Opioids Avoid opiods-especially oxycotin-as pain med for back or other pains-highly addictive-84% increase in deaths due to use of prescription given opiods reported over last 8-10 years. Is leading cause of death ages 25-55 Death 4 times more common than from illicit drug use. ? Given frequently by ER’s-? To get good patient satisfaction ratings.

20. Titles that Mislead 18% of published papers have titles that mislead- suggest a Positive outcome of a trial of a therapy not supported by documentation. The truth may be distorted in the conclusion. Conflicts of interest are important to note. Negative trails are not generally reported. Note the authors of studies on controversial screening recommendations. Does the author have a financial interest at stake if a recommendation will affect his profit making potential.

21. Pap Tests Pap tests are not felt needed under age 21 then q 2 years to mid or late 30’s, then q 10 years if all negative, and then not after age 65-70.

22. Screening Bone Density Screening bone density suggested started after age 65. If no increased risk of osteoporosis e.g. patient on steroid, past non-traumatic fracture, a smoker, thin, family history of excess fractures. Can be repeated every 5-10 years as screen.

23. Alendronate (fosamax) Alendronate (fosamax) decreases hip and vertebral fractures if bone density at hip <2.5. (long term use may lead to low energy fx femoral neck-osteonecrosis of jaw). Estrogen use decreases hip fracture and vertebral fractures-may increase risk of clots Forteo and estrace reduce verebral fractures- not hip fractures.

24. Estrogen Estrogen may increase risk of breast cancer and heart disease.

25. Insomnia Elderly with insomnia do better if advised to go to bed only when sleepy and to get up when not sleepy. 55% improved to having no problem with this approach compared with 13% given a sedative e.g. Ambien (has been associated with an increased risk of various cancers).

26. Phentermine, Topamax, Naltrexone and Wellbutrin Phentermine combined with Topamax and Naltrexone combined with Wellbutrin have been approved for weight loss help-use resulted in 23+ pound loss in a year-? Any better than past products as help to sustain loss-no severe side effects reported. Exercise important. Sitting watching TV>2 hours/day in one study reported increased risk of diabetes, heart attack, and all cause mortality.

27. Humidifiers Humidifiers do not increase incidence of respiratory illnesses in the winter.

28. Prednisone Prednisone use lead to lower ventilator use, lower death rate and lower readmission rate when compared to similar degree of illness of patients treated in hospital with IV steriods. Hospital stays shorter in prednisone group as well. 60 mgm of prednisone daily x 5 days or 16 mgm poqd of decadron x 2 days improved 90% of moderately severe asthmatics. Acute severe pnuemonia patients treated with decadron x 4 days had no adverse events and cut one day off the hospital stay.

29. Tylenol Tylenol given for ankle sprain with tear of lateral ligament was as effective for pain relief and reduced edema better when compared to use of a NSAID instead.

30. Steroid Injections A Steroid injected with ultrasound assistance into a join hit the target 83% of the time in a study that compared this with a steroid injected into a joint area without use of ultrasound-hit the target 66% of time. At the end of 2 weeks and 6 weeks post treatment symptom relief was the same.

31. Cell Phones and Cancer Cell phones do not significantly increase the risk of brain cancer-this per British study 2006. If used 30+ minutes/day same side of head X10 years increased incidence of brain tumor from 1 in 200,000 to one in 80,000 in another study. Cell phones increased risk of MVA x4 if used while driving-similar to blood alcohol of 0.8.

32. Blood Sugar Control Tight control of blood sugars in older diabetics with long standing problem no proven help. May harm with increased hypoglycemic episodes. This true with oral agents or insulin. ACCORD, ADVANCE, VADT studies and others found no decrease in mortality, CVAs, heart attacks, amputations etc with tight control. Some say results would be better if tight control started 10 years before the patients studied. British study 1999 found newly diagnosed diabetes tightly controlled showed no improvement in all cause mortality, cardiovascular mortality, diabetes related mortality. Metformin lowered mortality. Metformen + a sulfonylurea or insulin did not. Some have suggested a Hgaic 7-9% ok in older type 2 diabetes.

33. PSA PSA should be done as a screening after discussion with patient about possible consequences of a + result-this is at any age- and not after age 75. In past suggested done on all age 50 and up-some ethnic groups (African Americans) sooner.

34. Colonoscopy Screening Colonoscopy screening suggested age 50 and q 10 years-some patients have been told q 7 years.

35. Mamograms ? Mamograms suggested q 2 years and stop age 75.

36. Medical Statistics Joe Qeenan wrote in the Wall Street Journal May 12: Needed-a Cure for Medical Statistics. Joe had read obese fliers were at risk of seat belt failures-had planned trip to Las Vegas-was overweight. Decided to diet-starting eating yogurt instead of pancakes and sausage at breakfast. Read yogurt high in calories and a silent killer. Started low fat muffins instead-read these had high calories also and low Cholesterol can cause cancer, anxiety and depression. Was going to start antidepressant but read these made ineffective by pain killer he uses for neck pain. Started eating granola bars-read high in sugar-could cause pre- diabetes or diabetes, especially if eaten fast. Read Las Vegas was experimenting with driverless cars on their streets. Decided to stay home.

37. Bottom Line: Don’t believe everything you see or hear. What is gospel today may be heresy tomorrow.