1. HBPC Clinical Safari: Management Pearls and Pitfalls for the “Big 5” High Impact Conditions
Moderator:
Tom Lally, MD
Panelists:
Duane Kirskey, MD MSCE
Lynn Beatty, MD
Jon Salisbury, MD
David Skorvan, ANP

2. Disclosures Lally – Kindred Healthcare - Employee
Skorvan – no relevant disclosures
Beatty – Visiting Physicians Association – Employee
Salisbury – no relevant disclosures
Kirksey – no relevant disclosures

3. Objectives
Explain the clinical significance of the following conditions in the home-based setting:
CHF
Behaviors in Dementia
VTE
Recurrent Falls
Decubitus Wounds
Discuss potential challenges of implementing best practices in the management of these conditions in the home-based setting.
Identify practical ways to incorporate treatment strategies for these conditions into home-based medical practice.

4. Heart Failure at Home Jon Salisbury, MD
Visiting Physician Services – A member of VNA Health Group

5. Heart Failure At Home
“I haven’t sent a heart failure patient to the hospital in over 5 years”

6. Heart Failure
Pathophysiologic: Inability of heart to deliver blood and oxygen
Clinical: Breathlessness and fatigue associated with cardiac disease
Associated by: Fluid retention, edema, elevated venous pressure
Clinical assessment seeks to answer to questions:
Are the symptoms cardiac of non-cardiac in origin?
If cardiac, what is the precise problem?

7. Diagnostic Algorithm Dyspnea Fatigue Edema Dyspnea & fatigue
Previous MI
Angina
Hypertension
Valvular disease
Palpitations (arrhythmia?)
Smoking, alcohol abuse, family history
Tachycardia
Rales
Raised J.V.P.
Murmur
Edema
3rd heart sound
EKG
CXR
Echocardiogram
CBC, CMP, BNP
Thyroid Panel

8. Diagnostic Algorithm Continued
Systolic LV dysfunction (most common)
Diastolic LV dysfunction
Valvular disease
Rhythm / conduction disturbance
Pericardial / endocardial disease
Congenital heart disease

9. New York Heart Assoc. Functional Classification and Treatment

10. Pharmacologic Management
ACE Inhibitors:
Enalapril: 10mg BID
Lisinopril: 20 – 40mg QD
Captopril: 100 – 150mg daily (3 times daily dosing)
B-Blockers:
Carvedilol: BID x 2 weeks, then double every 2 weeks to highest level tolerated (dizziness) to max 25mg BID
Metoprolol succinate: 25mg QD (severe HF, start 12.5mg BID)
Bisoprolol: 1.25mg/day, max 5mg/day
Hydralazine: 300mg/day (divided doses)
Isorbide dinitrate: 30 – 160 mg/day

11. Pharmacologic Management Continued
Loop Diuretics:
Furosemide: 20 – 80mg/day
Bumetanide: .5 – 2mg/day
Metolazone: 2.5 – 5mg/day (often 3X/week)
Aldosterone Antagonists:
Spironolactone: 25 – 50mg/day
Eplerenone: 25 – 50mg/day
Digoxin: mg/day
ARB’s
Valsartan: 40mg/BID (start), 80 – 60mg/BID maintenance
Candesartan: 4mg/day start, target 32/day
Losartan: (not approved but beneficial) 50mg/day

12. Non-Pharmacologic Treatment
Diet: weight reduction, nutritional status, Na+ intake
Fluid Intake: about 2 liters/day
Smoking: stop or reduce
Exercise: regular moderate physical activity should be encouraged
Alcohol: in moderation
Vaccinations: influenza and pneumococcal

13. What We Also Do Education, education, education!
Patient and family involvement and decision making
Assess the patient for depression and stressors
Involvement of home nursing care, PT, medications management, CHF programs
Telemonitoring

14. Education Explain clearly what heart failure is
Explain medications, how they work, dosing schedule, etc…
Explain how their disease may be just as easily be well managed at home
Reassure patient that the diagnosis of heart failure does not have to be a death sentence
Include family / caregivers in education process

15. Additional Management
Daily weights:
Gain > 3lbs, take extra Lasix first, then call us!
Sliding scale of diuretics:
Involve patient and family in dosing schedules
What triggers ER visits?
Usually dyspnea, suggest use of pulse oximetry for reassurance
Anxiety / panic: frequently will use a short acting anxiolytic
Have occasionally utilized MSIR for air hunger /anxiety
Treat depression
Have discussion about Palliative Care and Hospice Care

16. Conclusion Heart failure can be well treated at home
Admission and readmissions can be significantly reduced
Follow treatment guidelines
Involve patient, family, and caregivers in decision making
Educate!
Discuss hospice / palliative with critical patients
Be reassuring that there can be life after diagnosis of heart failure!

17. Dementia

18. What is dementia?

19. Normal Aging

20. Mild Cognitive Impairment

21. Dementia

22. Dementia Subtypes Subtype % of dementia patients afflicted Progressive
Life Expectancy from onest
Alzheimer’s
65%
Yes 12
Vascular
30%
Maybe ?
Lewy Body
10% 6
Frontal Temporal
ETOH
<5%
Parkinson’s Dementia
<3%
Probably
Other….

23. Understanding Alzheimer’s
Notebook Analogy: memories are stored much like writing notes in a notebook.
You need both a pen and a notebook!
Page one are your oldest historical memories, (Age three)
Memories are stored in sequential order on subsequent pages.
Onset of Alzheimer’s is when the pen begins to run out of ink!
Next the pages are torn from the notebook, starting from the back and slowly moving forward.

24. Behaviors, Non-Pharmaceutical Treatments
Engagement, (preventive)
Games, hangman vs trivial pursuit…..
Activities: art, music
Outings
Meals
Redirection
The first chapter of their memory book
Distraction
One to one sitter
Music
Sensory room
MORE INFO AT: dementia-agitation-aggression-report pdf

25. Pharmaceutical Interventions for Behaviors
Make sure there are no reversible causes!
Diagnose the subtype of dementia
Exhaust non pharm interventions
Implement robust behavioral tracking system
Consider medical options
Evaluate urgency, is there high short term risk?
Select a pharmaceutical intervention
Discuss and document Risk Benefit discussion
NOTHING IS FDA APPROVED!!!!

26. Classification of Behaviors in Dementia
Primary Symptom
Examples
Medication Class
Psychotic
Paranoia, delusions, halluciantions, confabulation
Antipsychotic (many options)
Neurotic
Anxiety, depression, OCD
???
Impulsive
Physical or verbal abuse without warning (no filter)
Antiepileptic, Valproic Acid or Carbamazepine
Pain Response
Pain can cause a variety of responses and should be considered as a potential cause of any class of behaviors
Pain Medication, APAP to MSO4
Agitation
General agitation that cannot be classified elsewhere. Yelling and pacing are common examples.
Citalopram, escitalopram, memantine

27. Antipsychotic Choice Quetiapine NO Low Sedating 12.5 – 400 mg/day $$$
FDA approved
Movement Side Effects
Activating or Sedating
Dose Range
Cost
Liquid Form Available
Frequency
Quetiapine NO
Low
Sedating
12.5 – 400 mg/day
$$$ No
BID-TID
Risperidone
High
Activating
0.25 – 4 mg/day
Yes
BID
Olanzapine
2.5 – 10 mg/day $$
QD-BID
Haloperidol
0.5 – 6mg/day ₵₵

28. Summary Rule out other causes, infection, medication, metabolic…?
Investigate and document specifics about the behaviors, behavioral log?
Risk Stratify the patient and behavior
Select medication and sig that best matches patient needs
Review and document Informed Consent while establishing realistic expectations
Educate staff or family about what to monitor
Schedule a close follow up, generally <10 days
Evaluate effect with staff and family
Repeat process as needed….
ALWAYS CONSIDER WEANING OR DISCHARGE OF THESE MEDS. We give all stable patients a weaning trial after 30 days of stability.

29. Venous Thromboembolic Disease
Duane Kirksey, MD MSCE
Cleveland Clinic Medical Care at Home

30. Venous Thromboembolic Disease (VTE)
HBPC Prevalence and Significance
Best Practices
Diagnosis
Treatment / Management
Challenges in Home Based Primary Care
When to Refer / Send to Hospital

31. VTE: Prevalence 3rd Leading Cause of Death1
Prevalence directly associated with Age2
Risk Factors
Virchow’s Triad:
Stasis
Hypercoagulability
Endothelial Injury

32. VTE: Prevalence Home Bound Adults
Lower Risk Than Community Dwelling Adults3,4
Risk Factors
Respiratory Infection, Recent General Surgery, Mobility Limitation5
Spinal Cord Injury (Paraplegia / Quadriplegia)
Low Risk after 90 days from injury6

33. VTE: Significance Home Bound Adults
Cross-sectional Study of Homebound Adults
18% with asymptomatic DVT7
No cases of symptomatic DVT

34. VTE: Best Practice Diagnosis Venous Ultrasound Mobile Radiology
Trained Clinician

35. VTE: Best Practice Acute Management / Treatment Anti coagulation
Low Molecular Weight Heparin (LMWH)
Direct Oral Anticoagulants (DOA)
Long Term Management / Treatment
Vitamin K Agonist (VKA)
Direct Oral Anticoagulants

36. VTE: Home Based Practice
Diagnostic Challenges
Availability of Ultrasound
Pulmonary Embolism
Acute Management Challenges
LMWH Delivery
DOA Cost / Formulary

37. VTE: Home Based Practice
Long Term Management
VKA
Monitoring
Interactions
DOA8,9
Chronic Kidney Disease
Weight Extremes
CYP3A4 and P-gp Interactions

38. VTE: Referral Diagnostics Unavailable
DOA to start if clinical suspicion and obtain diagnosis later
Clinically Unstable
Hypoxia
Hypotension

39. VTE References
Goldhaber SZ. Venous Thromboembolism: epidemiology and magnitude of the problem. Best Practice & Research Clinical Haematology 25 (2012):
Martinez C, Cohen AT, et al. Epidemiology of first and recurrent venous thromboembolism: A population-based cohort study in patients without active cancer. Blood Coagulation, Fibrinolysis and Cellular Haemostasis. 2014: – 263
Ahmed J, Ornstein K, Dunn A, Gilatio P. Incidence of Venous Thromboembolism in a Homebound Population. J Community Health :
Arpais G, Ambrogi F, et al. Risk of Venous Thromboembolism in Patients Nursed at Home or in Long-Term Care Residential Facilities. Int J of Vascular Medicine, 2011
Leibosn CL, Peterson TM, et al. Rethinking Guidelines for VTE Risk Among Nursing Home Residents: A population-Based Study Merging Medical Record Detail with Standardized Nursing Home Assessments. CHEST 2014;146(2):
Jones T, Ugalde V, et al. Venous Thromboembolism after spinal cord injury: Incidence, Time Course, and Associated Risk Factors in 16,240 Adults and Children. Arch Phys Med Rehabil December 2005 Vol – 2247
Cabral KP, Ansell JE The role of Factor Xa inhibitors in venous thromboembolism treatment. Vascular Health and Risk Management :
Adams SS, et al. Comparative Effectiveness of Warfarin and New Oral Anticoagulants for the Management of Atrial Fibrillation and Venous Thromboembolism: A Systematic Review. Annals of Internal Medicine 2012;157:

40. Falls in the Elderly – The Sensory Connection
Lynn Beatty, MD

41. Demographics In patients over 65:
20%of falls result in severe injuries (fracture or TBI)
2.5 million ER visits annually
700,000 patients/year hospitalized due to fall
>95% of hip fractures are caused by falling (usually falling sideways)
Direct medical costs for fall injuries = $34 billion annually (2/3 are for hospital costs)
-CDC Home and Recreational Safety, Falls among older adults, updated

42. Approach to Management of Fall Risk
Manage Modifiable Risk Factors
Environmental hazards
Medications
Metabolic factors
Musculoskeletal factors
Neuropsychologic factors
Sensory impairment invisible and often overlooked
Disease/Illness related
Moncada, Management of Falls in Older Persons, A Prescription for
Prevention, American Family Physician 2011;84(11):

43. Sensory Impairment 3 key sensory components of balance function:
Somato-sensory (touch, vibratory, proprioception)
Visual
Vestibular – the most “invisible” but also highly treatable

44. Vestibular Dysfunction
From % of US adults >40 had vestibular dysfunction (69 million Americans)
Increased prevalence with age (mediated by vestibular dysfunction)
40.3% lower risk in individuals with > high school education
70% higher among people with diabetes
Borderline increased risk in hypertension
8-fold increased risk of falling if symptomatic with dizziness; subclinical vestibular dysfunction also associated with increased risk
Agrawal, et al, Disorders of Balance and Vestibular function in US Adults, Data from the NHANES , Arch Intern Med, 169(10): , May 25, 2009

45. Vestibular Intervention
Vestibular evaluation
Vestibular exercises
Dynamic Visual Acuity (DVA)
Stare at object while shaking head; if object appears to shake or becomes blurry = deficit
Modified CTSiB
Stand upright under 4 sensory conditions x 30 s each
Stare at object while shaking head; while nodding head. Goal = 5 minutes total per day; safe to do alone on couch; PT can help increase challenge & duration

46. Principles of Wound Care
David Skovran, ANP
Mount Sinai Visiting Doctors Program

47. Prevalence
An estimated 2.5 million pressure ulcers are treated each year in acute care facilities in the United States
Prevalence of pressure ulcers is widespread in all settings with estimates of 10% to 18% in acute care, 2.3% to 28% in long term care, and up to 29% in home care (National Pressure Ulcer Advisory Panel, 2009)

48. Agency for Healthcare Research and Quality (2006 Analysis of pressure ulcers)
Pressure ulcer related hospitalizations ranged from 13 to 14 days and cost $16,755 to $20,430 per patient compared with average stay of 5 days and cost of about $10,000
Pressure ulcers were a secondary diagnosis in 457,800 hospital admissions, up from 245,600 in These patients admitted primarily for pneumonia, infections, or other medical problems, either developed pressure ulcers before or after admission

49. Pressure Ulcer Staging
Stage/Category I ulcers emerge without frank denudation or ulceration of skin that is red and nonblanchable.
Stage/Category II ulcers are partial thickness wounds involving the epidermis and dermis
Stage/Category III ulcers appear as full- thickness skin loss involving damage or necrosis of subcutaneous fat that may extend down to, but not through, underlying fascia
Haesler, E (Ed.). National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel and Pan Pacific Pressure Injury Alliance. Prevention and Treatment of Pressure Ulcers: Quick Reference Guide. [Internet] Available from:

50. Pressure Ulcer Staging continued
Stage/Category IV ulcers present with full thickness tissue loss; deep tissue layers such as muscle, tendon, ligaments or bone are visible.
Unstageable ulcers present as full thickness skin loss but the true depth of the ulcer is obstructed by necrotic tissue in the form of slough or eschar.
Suspected Deep Tissue Injury (DTI) characteristically presents as either a blood-filled blister or ecchymosis with purple or maroon colored intact skin

51. Stage 1

52. Stage 2

53. Stage 3

54. Stage 4

55. Stage 4

56. Pressure Ulcer Prevention
Turning and positioning
Frequently turn and reposition lying patients every 2 hours and seated patients every 15 minutes.
Friction and Shear forces:
Prolonged upright positioning and repositioning of the body without surface barriers such as a sheet can subject the body to both persistent and dynamic shear forces.
The repositioning interval can be prolonged up to 4 hours for recumbent positions and 1 hour for seated persons when using pressure- reducing surfaces although this practice has not been validated
Proper repositioning is important for home-based medical care providers to understand; providers should instruct caregivers and interdisciplinary personnel on accepted methods for high-risk patients and for those with existing ulcers
Pressure-relieving devices including foam or pillow off-loaders and static and dynamic bed surfaces coupled with proper positioning and repositioning schedules can reduce risk.
Krapfl, LA, Gray, M. Does Regular Repositioning Prevent Pressure Ulcers? Journal of Wound, Ostomy and Continence Nursing 2008; 35(6):

57. Pressure Ulcer Prevention
Support Surfaces
Group 1: considered preventative – composed of gels, foam, water or air
Group 2: Composed of powered low air loss mechanism
Group 3: Composed of fluidized-air
and particulates such as silicone beads
Group 1 support surfaces are covered by US Medicare if the person meets several risk criteria including immobility, incontinence, poor nutritional state, circulatory compromise or sensory impairment or has any stage pressure ulcer on the body.
covered by US Medicare only if several more stringent criteria are met including one of the following: the presence of multiple stage 2 ulcers, or large or multiple stage 3 ulcers, or stage 4 pressure ulcers on the trunk or pelvis
Group 3 support services offer the greatest pressure redistribution and are reserved for patients with reserved for severely immobile patients with stage 3 or stage 4 pressure ulcers who would require institutionalization if the device were not provided and have failed therapy with a group 2 device.
Alvarez OM, Kalinski C, Nusbaum J, Hernandez L. Pappous E, Kyriannis C, Parker R, Chrzanowski G, Comfort C. Incorporating Wound Healing Strategies to Improve Palliation (Symptom Management) in Patients with Chronic Wounds. J Pall Med. 2007; 10(5):

58. Cleansing Wounds Clean with each dressing change
Minimizing trauma to the surrounding skin.
Recommended that the ulcers be cleaned with non- cytotoxic cleansers such as saline or water
In general, povidone-iodine solution, hydrogen peroxide, isopropyl alcohol and sodium hypochlorite (bleach) marketed as Dakin’s solution should be avoided given their high destruction of viable tissue and imposed delay in wound healing except in select circumstances.
Kelechi T, Johnson JJ. Guideline for the Management of Wounds in Patients With Lower-Extremity Venous Disease. JWOCN 2012;39(6):

59. Debriding the Wound Autolytic:
the use of dressings and formulations that promote the body’s natural enzymes to continually remove cellular debris from the wound
Usually done by any dressing that keeps wound moist, such as hydrocolloids and hydrogels
Enzymatic:
Enzymes degrade and remove necrotic tissue (examples: Collagenase, Sodium Chloride marketed as Hypergel)
Used when large amounts of slough or with some eschar
Some sting/inflammation
Shi L, Carson D. Collagenase Santyl ointment: a selective agent for wound debridement. J Wound Ostomy Continence Nurs. 2009;37(6 Suppl):S12–16.

60. Debriding the Wound
3. Non-enzymatic debridement: Sodium hypochlorite (bleach) or marketed as Dakin’s Solution™
Topical, broad spectrum antimicrobial with efficacy in the clinical setting of MRSA, Vancomycin-resistant enterococcus and other antibiotic resistant bacteria, is widely used in a variety of difficult wound types
It is often used at ¼ strength to limit toxicity to surrounding tissue
Nisbet HO, Nisbet C, Yarim M, Guler A, Ozak A. Effects of Three Types of Honey on Cutaneous Wound Healing. Wounds.2010;22(11):

61. Debriding the Wound Sharp Debridement
Indicated when chemical debridement has been unsuccessful or when more rapid tissue closure is desired
Necrotic tissue is removed using a scalpel, scissors, forceps, or curette

62. Choice of Wound Care Dressings
Stage 1 ulcers and Suspected Deep Tissue Injury
In areas of moisture or irritation from urine or feces, an moisture barrier such as vitamin A/D cream or zinc oxide may be used.
A thin adhesive barrier such as a transparent dressing or thin hydrocolloid is advised to limit friction.

63. Choice of Wound Care Dressings
Hydrocolloids (marketed as: DuoDerm, Comfeel, Tegasorb, Restore):
Hydrophillic colloid particles bound to polyurethane foam
Remain in place for 5-7 days. Often used to “seal” a wound that is otherwise clean in order to promote healing.
NOT for heavy drainage

64. Choice of Wound Care Dressings
Stage 2 Ulcers:
Superficial and minimal drainage wounds
Petrolatum dressing (example: Xeroform)
Hydrocolloid
Sodium based (example: Hydrogel)
More Exudative
Packing with calcium alginate (example: Algisite) or sodium carboxymethylcellulose (example: Hydrofibers)

65. Choice of Wound Care Dressings
Sodium Based – (example: Hydrogels)
Water-based, non adherent crossed linked polymer, hydrophilic. Keep the wound bed moist and cool

66. Choice of Wound Care Dressings
Petrolatum – (example: Xeroform)
A sterile, fine mesh gauze impregnated with a blend of 3% Bismuth Tribromophenate USP Petrolatum
Helps maintain a moist wound environment

67. Choice of Wound Care Dressings
Calcium Algisite
Calcium-sodium salts of alginic acid (seaweed)
Useful to fill cavities, pockets, undermining, moisture retentive
Not recommended for use in wounds with low drainage as the dressing can dry out the wound
Also available impregnated with silver, offers additional barrier to bacterial growth

68. Choice of Wound Care Dressings
Hydrofibers (marketed as Aquacel):
How it works: Like an alginate, the absorption of wound fluid causes this synthetic carboxymethylcellulose fiber to create a gel with enhanced absorption over alginates.
Available impregnated with silver
The benefit over alginates is that the frequency of wound care dressings can be several days longer.  
Barnea Y, Weiss J, Gur E. A review of the applications of the hydrofiber dressing with silver (Aquacel Ag®) in wound care. Therapeutics and Clinical Risk Management 2010;6:21-7.

69. Choice of Wound care Dressings
Stage III and IV Ulcers: treated similarly
The goal is to fill the crater bed with the right material to promote absorption while maintaining a moist, bacteria-free wound environment
Less Exudative:
Pack with Hydrogels
More Exudative
Pack with Alginates or Hydrofibers
Consider Silver impregnated fibers

70. Venous Stasis Ulcers
Chronic leg ulcers caused by chronic venous insufficiency (CVI) are the second most common wound-type treated in home-based primary care settings.
Poorly functioning vein valves or venous occlusion causes CVI
Risk factors for CVI include age (over the age of 30), family history, female sex, repeated venous thromboses, multiple pregnancies and obesity. Behavioral factors including prolonged standing and sitting, and heavy lifting
Eberhardt RT, Raffetto JD. Chronic Venous Insufficiency. Circulation. 2014;130:

71. Venous Stasis Ulcers Treatment:
Compression is the mainstay of effective venous stasis ulcer care.
There are two main options for compression:
Paste bandage impregnated with zinc oxide, glycerin and gelatin – marketed as the Unna boot
Multi-layer compression bandaging system – marketed as Profore™
The Unna boot consists of a paste bandage that is impregnated with zinc oxide, glycerin and gelatin. It is applied without tension in a circular fashion from the foot just distal to the metatarsals to below the knee. An elastic wrap or tubular support bandage is applied as a final layer and forms a cast after drying. The Profore ™ dressing is composed of four layers. The first layer is an absorbent padding. The second layer is a light conforming wrap that is also wrapped in a spiral fashion with 50% overlap. The third layer is a compression layer. This will apply about 17mmHg pressure. The fourth layer is also compression. It is wrapped in a spiral fashion with 50% overlap and 50% stretch, which results in 20mmHg pressure. A systematic review comparing the Unna boot with the four-layer compression dressing showed no differences in the effectiveness of healing venous stasis ulcers
O’meara S, Cullum N, Nelson EA, Dumville JC. Cochrane Database Syst Rev. 2012 Nov 14;11:CD

72. Wound References
Haesler, E (Ed.). National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel and Pan Pacific Pressure Injury Alliance. Prevention and Treatment of Pressure Ulcers: Quick Reference Guide. [Internet] Available from: 14-Quick-Reference-Guide-DIGITAL-NPUAP-EPUAP-PPPIA-16Oct2014.pdf.
Krapfl, LA, Gray, M. Does Regular Repositioning Prevent Pressure Ulcers? Journal of Wound, Ostomy and Continence Nursing 2008; 35(6):
Alvarez OM, Kalinski C, Nusbaum J, Hernandez L. Pappous E, Kyriannis C, Parker R, Chrzanowski G, Comfort C. Incorporating Wound Healing Strategies to Improve Palliation (Symptom Management) in Patients with Chronic Wounds. J Pall Med. 2007; 10(5):
Kelechi T, Johnson JJ. Guideline for the Management of Wounds in Patients With Lower-Extremity Venous Disease. JWOCN 2012;39(6):
Shi L, Carson D. Collagenase Santyl ointment: a selective agent for wound debridement. J Wound Ostomy Continence Nurs. 2009;37(6 Suppl):S12–16.
Nisbet HO, Nisbet C, Yarim M, Guler A, Ozak A. Effects of Three Types of Honey on Cutaneous Wound Healing. Wounds.2010;22(11):
Barnea Y, Weiss J, Gur E. A review of the applications of the hydrofiber dressing with silver (Aquacel Ag®) in wound care. Therapeutics and Clinical Risk Management 2010;6:21-7.
Eberhardt RT, Raffetto JD. Chronic Venous Insufficiency. Circulation. 2014;130:
O’meara S, Cullum N, Nelson EA, Dumville JC. Cochrane Database Syst Rev. 2012 Nov 14;11:CD

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