Glib aside: sulphonylureas in advanced kidney disease
Recent, BMJ Evidence Based Medicine (EBM) articles have highlighted a number of concerns pertaining to academic validity in medical guidelines. In the September 2019 issue, Braithwaite1 decried a ‘startling disconnect’ between EBM theory and the processes by which academic authorities accumulate and communicate evidence. Meanwhile, in the February 2020 issue, Bareket et al2 noted the often inadvertent accumulation of error through authors ‘citing non-primary data and amplifying the errors of their predecessors’. Taken together, these procedural errors erode the academic backbone of medical guideline...
Source: Evidence-Based Medicine - November 25, 2021 Category: Internal Medicine Authors: Shand, J., Bradley, K. Tags: Letters Source Type: research
Epinephrine should continue to be used in the treatment of out-of-hospital cardiac arrest
EBM verdict EBM Verdict on: Perkins GD, Ji C, Deakin CD, et al. A randomized trial of epinephrine in out-of-hospital cardiac arrest. N Eng J Med 2018;379:711–21. doi: 10.1056/NEJMoa1806842. Epinephrine standard dose (1 mg) should be used in out-of-hospital adult cardiac arrest as per current Advanced Life Support guidelines, however, resuscitation teams’ focus should be directed towards early defibrillation and high quality cardiopulmonary resuscitation where appropriate. Intravenous epinephrine has been a mainstay of resuscitation practice for many years, but evidence for its efficacy is scarce. The Prehospita...
Source: Evidence-Based Medicine - November 25, 2021 Category: Internal Medicine Authors: Hafeez, A., Novak, A. Tags: Emergency care, EBM Verdict Source Type: research
Alcohol and atrial fibrillation: to or not to drink?
EBM Verdict EBM Verdict on: Voskoboinik A, Kalman MJ, Silva DA, et al. Alcohol Abstinence in Drinkers with Atrial Fibrillation. N Engl J Med 2020; 382:20–28. DOI: 10.1056/NEJMoa1817591 In patients with (AF who are regular drinkers of 10 or more standard rinks a week) an alcohol abstinence programme leads to 20% (95% CI 4.3% to 36%) less exacerbations of AF: number needed to treat 5 (95% CI 3 to 28). Alcohol has long been considered a risk factor for atrial fibrillation (AF). However, it has been uncertain whether reducing alcohol consumption reduces the risk of AF exacerbations as there has been no evidence from rand...
Source: Evidence-Based Medicine - November 25, 2021 Category: Internal Medicine Authors: O'Sullivan, J. W. Tags: General Medicine, EBM Verdict Source Type: research
Should patients with atrial fibrillation and stable coronary artery disease receive an oral anticoagulant, an antiplatelet or both?
Patients with atrial fibrillation necessitating anticoagulation frequently develop concomitant stable coronary artery disease requiring antiplatelet therapy and vice versa. The optimal choice of antithrombotic therapy in this cohort has been unclear. Which therapy is most effective at reducing mortality and thrombotic events while avoiding a disproportionate increase in bleeding risk? EBM verdict EBM Verdict on: Antithrombotic therapy for atrial fibrillation with stable coronary disease. N Engl J Med 2019;381:1103-–1113. doi: 10.1056/NEJMoa1904143. In patients with atrial fibrillation and stable coronary artery disea...
Source: Evidence-Based Medicine - November 25, 2021 Category: Internal Medicine Authors: Mills, M. T. Tags: General Medicine, EBM Verdict Source Type: research
Consider a CT angiogram before invasive coronary angiogram in patients with NSTEMI
Patients with non-ST-elevation myocardial infarction (NSTEMI) may have coronary artery disease requiring revascularisation. However, many patients with NSTEMI do not. CT angiogram appears to be an effective way to stratify these patients. Patients with non-ST-elevation myocardial infarction (NSTEMI) present a challenging clinical conundrum.1 Some of these patients have severe coronary artery disease requiring urgent revascularisation, while others have such little coronary stenosis that no revascularisation nor antithrombotic treatment is, ultimately, required. The difficulty facing clinicians is how they can identify thos...
Source: Evidence-Based Medicine - November 25, 2021 Category: Internal Medicine Authors: O'Sullivan, J. Tags: General Medicine, EBM Verdict Source Type: research
Preventing hospital readmission through better medication continuity after hospital discharge
The transition from hospital-to-home is a common source of medication-related problems among older adults, some of which lead to hospital readmission. The prevalence of these problems is amplified by an ageing population and an increasing number of unplanned hospital admissions. Clinicians who integrate bundles of simple interventions, such as medication reconciliation, self-management education and telephone follow-up for older patients during discharge are likely to see reductions in hospital readmissions. Medication-related problems, such as reconciliation errors, patient confusion, inappropriate continuation or discont...
Source: Evidence-Based Medicine - November 25, 2021 Category: Internal Medicine Authors: Collins, D. Tags: General Medicine, EBM Verdict Source Type: research
Small intestine-release peppermint oil is beneficial in the treatment of irritable bowel syndrome
Evidence from systematic reviews has suggested that peppermint oil is an effective agent for the management of irritable bowel syndrome; however, results of a recent trial show that the type of formulation can affect the extent of benefits. Irritable bowel syndrome (IBS) is a chronic functional disorder that is thought to affect up to 20% of the general population.1 Its symptoms primarily include abdominal pain and altered bowel habits. Management includes changes to diet and lifestyle and the use of medications. The results of published systematic reviews have suggested that peppermint oil is effective for the treatment o...
Source: Evidence-Based Medicine - November 25, 2021 Category: Internal Medicine Authors: Onakpoya, I. Tags: Primary care, EBM Verdict Source Type: research
No role for tranexamic acid in the treatment of acute gastrointestinal bleeding
The HALT-IT Trial has shown that tranexamic acid does not improve outcome in acute gastrointestinal bleeding and may instead increase the risk of complications. Tranexamic acid (TXA) is an antifibrinolytic drug proven to reduce death due to bleeding in trauma,1 postpartum haemorrhage2 and head injury.3 A Cochrane meta-analysis of 1701 patients showed a large reduction in all-cause mortality with the use of TXA in upper gastrointestinal bleeding.4 The HALT-IT trial was planned as an international, multicentre, randomised, double-blind, placebo-controlled trial to evaluate the effect of TXA in acute upper and lower gastroint...
Source: Evidence-Based Medicine - November 25, 2021 Category: Internal Medicine Authors: Erasu, V., Novak, A. Tags: Emergency care, EBM Verdict Source Type: research
Early salvage versus adjuvant therapy for treatment of prostate cancer following prostatectomy
The prospective adaptive meta-analysis by the ARTISTIC collaboration did not demonstrate that adjuvant radiotherapy following radical prostatectomy improves event-free survival over early salvage radiotherapy. Early salvage is preferred over adjuvant therapy to reduce overtreatment and associated side effects. In patients with localised prostate cancer, the goal of radical prostatectomy is to remove the entire primary tumour. This goal is reached in some patients, but in others, cancerous tissue may be left behind. To protect against local recurrence in high-risk patients, the prostate bed is commonly irradiated after radi...
Source: Evidence-Based Medicine - November 25, 2021 Category: Internal Medicine Authors: Garriga, M., Feng, F. Y., Lee, W. R., Hong, J. C. Tags: EBM Verdict Source Type: research
Tranexamic acid in acute traumatic brain injury
The incidence of traumatic brain injury (TBI) is rising, with over 60 million people affected annually across the globe.1 Tranexamic acid (TXA) is an inhibitor of fibrinolysis, which is readily available, easily administered, can be given in the prehospital phase and has been shown to have a good safety profile in trauma.2 Following the CRASH-2 trial, which showed a significant reduction in deaths from major extracranial bleeding in patients who had TXA administered within 3 hours of injury, CRASH-3 (Effects of tranexamic acid on death, disability, vascular occlusive events and other morbidities in patients with acute trau...
Source: Evidence-Based Medicine - November 25, 2021 Category: Internal Medicine Authors: Baron, T., Novak, A. Tags: Emergency care, EBM Verdict Source Type: research
Should clinical practice change to bedtime administration of antihypertensive?
Chronotherapy provides a new option to optimise hypertension and reduce cardiovascular risks based on the circadian profile of blood pressure.1 A recent Hygia trial reported taking bedtime antihypertensives reduced cardiovascular disease (CVD) risk by 45% compared with ingestion of medications on awakening.2 However, two key points related to the design and reporting of this trial should be considered in developing guidelines for optimal timing of antihypertensive use. The Hygia trial reported that there was no treatment-time difference in prevalence of all adverse events and sleep time hypotension. Unexpectedly, they did ...
Source: Evidence-Based Medicine - November 25, 2021 Category: Internal Medicine Authors: E, J.-Y. Tags: Letters Source Type: research
What is the most appropriate respiratory protection against COVID-19?
The world is suffering from a pandemic of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2 or COVID-19), with a mortality rate of up to 4%.1 COVID-19 infection is seen at disproportionately high levels among healthcare workers. Current UK guidance regarding the use of personal protective equipment (PPE) for COVID-19 was updated in April 2020.2 For close contact (<2 metres), the recommended respiratory protection remains a fluid-resistant surgical face mask. However, for areas at higher risk of aerosols, or during aerosol generating procedures, the use of filtering face piece (FFP) mask is advised. These high-...
Source: Evidence-Based Medicine - November 25, 2021 Category: Internal Medicine Authors: Burr, N. E., Black, C. J. Tags: COVID-19 Letters Source Type: research
Delays in publishing systematic review registrations in PROSPERO are hindering transparency and may lead to research waste
PROSPERO is an international prospective registry of systematic reviews.1 Registering a systematic review prospectively is considered a good research practice for multiple reasons, including transparency of the planned methods and prevention of unnecessary duplication of effort. Solla et al2 recently reported concerns that PROSPERO registration may not prevent double review on the same topic because the PROSPERO search engine is apparently failing in finding similar review projects. Another pertinent current problem of PROSPERO may hinder intended transparency and promote research waste and duplication efforts, namely, maj...
Source: Evidence-Based Medicine - November 25, 2021 Category: Internal Medicine Authors: Puljak, L. Tags: COVID-19 Letters Source Type: research
'Is there racism in academic medical publishing?
We read with great interest the BMJ issue devoted to issues confronting doctors and patients from ethnic minority backgrounds.1 2 We applaud the Journal for its courage in tackling such a sensitive issue. We the undersigned, academic clinicians from a lower middle-income country (LMIC), Sri Lanka, would like to highlight another aspect of the problem—that is, discrimination in academic medical publishing that borders on racism. Academia and the scientific community are not immune to discrimination, however subtle, and the academic publication process is an area which deserves to be examined. It is widely acknowledged...
Source: Evidence-Based Medicine - November 25, 2021 Category: Internal Medicine Authors: Niriella, M. A., De Silva, A. P., de Silva, H. J., Jayasinghe, S. Tags: Letters Source Type: research
Thrombolysis with alteplase 3-4.5 hours after acute ischaemic stroke: trial reanalysis adjusted for baseline imbalances
We congratulate Alper et al for their reanalysis of the Third European Cooperative Acute Stroke Study.1 They found that after adjusting for baseline imbalances in history of prior stroke and stroke severity, there was no statistical benefit with alteplase, but the harms were reconfirmed. So, the difference in outcome could be fully explained by the baseline imbalance. It is worth remembering that a clinical trial has internal validity if and only if the imbalance between groups, bias in the assessment of outcome, and chance have been excluded as possible explanations for the difference in outcomes. It also reaffirms the fr...
Source: Evidence-Based Medicine - November 25, 2021 Category: Internal Medicine Authors: Fatovich, D. M., Milne, W. K. Tags: Letters Source Type: research
