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1641. Gingival and plaque decontamination: Can we take a bite out of VAP? Full Text available with Trip Pro

[ ]. Although evidence from more than 50 clinical trials and ten meta-analyses demonstrate that selective decontamination of the digestive tract (SDD) using topical antibiotics (+/- systemic antibiotics) is associated with decreased incidence of VAP, routine implementation of SDD has not been adopted by most intensivists because of concerns about the emergence of antibiotic-resistant pathogens. Topical application of an antiseptic , such as chlorhexidine, could be an attractive alternative for oropharyngeal (...) pneumonia, a number of methodological limitations may have reduced the likelihood of showing an impact for the intervention. Because rates of VAP were much lower than anticipated, the study was underpowered. Two-thirds of the subjects were considered infected at the time of ICU admission (primarily bronchitis and community-acquired pneumonia) and prior antibiotic usage was not an exclusionary criterion for entry into the study, making interpretation of rates of new respiratory infections challenging

2006 Critical Care - EBM Journal Club

1642. PICCing the best access for your patient Full Text available with Trip Pro

not know many details of the parent trials that might help in our interpretation of the data, such as how long subjects were in the hospital or ICU, what antibiotics they received prior to PICC insertion, or how long antibiotics were given. Some patients in the parent trials received conventional CVCs. Rates of CVC-related BSI for these subjects were not reported and instead the authors provide reported rates from the literature to put the observed PR-BSI rates in perspective. PICC-related risks

2006 Critical Care - EBM Journal Club

1643. Drotrecogin alfa (activated) should not be used in patients with severe sepsis and low risk for death Full Text available with Trip Pro

to antibiotics ▪ Early broad-spectrum antibiotics ▪ Narrowing antibiotic therapy based on microbiology and clinical data ▪ Source control ▪ Stress-dose steroids for septic shock ▪ DrotAA for patients with severe sepsis and high risk for death ▪ Target hemoglobin values of 7–9 g/dL in absence of coronary artery disease or acute hemorrhage ▪ Lung protective ventilation for ALI/ARDS ▪ Semirecumbent bed position ▪ Protocols for weaning and sedation/analgesia ▪ Avoidance of neuromuscular blockers ▪ Maintenance

2006 Critical Care - EBM Journal Club

1644. Dexamethasone in Benign Headaches

. Unfortunately, this desire to help our patients has often led us to wide-scale adoption of treatments that were used in thousands of patients before ultimately being proven unsound. Allow me to point to some historical treatments, such as steroids in septic shock, aminophylline in status asthmaticus, prophylactic lidocaine in acute MI, eye patching for corneal abrasion, the pneumatic anti-shock garment in hemorrhagic shock, forced IV fluids for ureteral stones, magnesium in acute MI, antibiotics for acute

2007 Sinai EM Journal Club

1645. The Paining, Part I (Morphine in acute abdomen)

from 98 to 65, on average, whereas the placebo group went from 99 to 97. Diagnostic discordance occurred 11 times in each group, meaning that accuracy wasn’t affected by analgesia. The dictum to avoid analgesia in abdominal pain dates to a 1921 proclamation by Sir Zachary Cope — a good example of emminence-based medicine. Maybe this warning was appropriate in the age before antibiotics and CT scanners, but we now have eleven trials in the last twenty years showing that Cope doesn’t cut

2006 Sinai EM Journal Club

1646. A simplified version of the Walsh clinical prediction rule was accurate for detecting streptococcal pharyngitis Full Text available with Trip Pro

) (table). Conclusion In adults with symptoms of upper respiratory tract infection or sore throat, the simplified version of the Walsh clinical prediction rule was accurate for detecting the presence of group A β haemolytic streptococcal pharyngitis. Commentary Although most sore throats lead only to temporary illness, streptococcal pharyngitis may have prolonged symptoms and sometimes local suppurative and serious immune complications. Antibiotic treatment decreases symptoms, reduces transmission (...) HP, et al. The diagnosis of strep throat in adults in the emergency room. Med Decis Making 1981 ; 1 : 239 –46. McIsaac WJ, White D, Tannenbaum D, et al. A clinical score to reduce unnecessary antibiotic use in patients with sore throat. CMAJ 1998 ; 158 : 75 –83. Poses RM, Cebul RD, Collins M, et al. The importance of disease prevalence in transporting clinical prediction rules. The case of streptococcal pharyngitis. Ann Intern Med 1986 ; 105 : 586 –91. View this table: Likelihood ratios for GABHS

2004 Evidence-Based Medicine

1647. Review: evidence on the effectiveness of interventions to assist patient adherence to prescribed medications is limited Full Text available with Trip Pro

included simplified dosing regimens for those taking antihypertensive and lipid lowering medications and counselling about the importance of full adherence to antibiotic regimens reinforced by written instructions. Conclusion In patients with medical or mental disorders, limited evidence suggests that several interventions designed to assist patients’ adherence to prescribed medications may be effective. Commentary Healthcare providers tend to see their job as making decisions about care

2004 Evidence-Based Medicine

1648. Oral or intravenous thiamine in the emergency department

Wernickes encephalopathy] is [parental delivery of thiamine better than the oral route] at[achieving bioavailability without side effects]? Clinical Scenario A 56 year old male attends the emergency department with cellulitis in his left leg. He is unkempt and drinks heavily. The cellulitis can be treated as an out patient with oral antibiotics, but you suspect he is thiamine deficient as a result of chronic alcohol abuse. You are therefore about to prescibe an intravenous infusion of thiamine as you

2004 BestBETS

1649. Wound closure in animal bites

OR OR exp adhesives OR] LIMIT to human AND English language. Search Outcome Altogether 74 papers were found of which 1 provided the best evidence to answer the clinical question. Relevant Paper(s) Author, date and country Patient group Study type (level of evidence) Outcomes Key results Study Weaknesses Maimaris C & Quinton DN, 1988, UK 96 ED patients with 169 dog bite lacerations (punctures excluded) randomised to primary closure or leaving wound open No antibiotics PRCT Infection 7 (...) versus non-closure. No antibiotics were used in this study. It excludes puncture wounds, wounds infected at presentation, wounds with other structures involved, and those requiring plastic surgery. The study concludes that there is no significant difference in infection rates between the two groups except in those wounds occurring to the hands. Significantly more hand wounds became infected than wounds elsewhere, and of all hand wounds significantly more became infected in the group treated

2004 BestBETS

1650. Full blood count and reticulocyte count in painful sickle crisis

Size No cases of aplastic anemia. Suspicion of aplastic anemia No patients were suspected to have aplastic anemia before or after reticulocyte cell count was available. Chapman JI 2004 USA 30 children with 86 presentations. A complicated presentation was defined as one that required admission, antibiotics, blood products, or resulted in acute chest syndrome within forty-eight hours. Retropective study Haematologic differences between complicated and uncomplicated patients None Retrospective Small

2006 BestBETS

1651. Administration of steroids in acute exacebations of COPD

Question In [patients with an acute exacerbation of COPD] are [steroids prior to discharge better than no steroids] at [improving outcome and hastening recovery]? Clinical Scenario A 55yr old man, known to have COPD comes to casulty more short of breath than usual and with a history of recently coughing purulent sputum. You treat him in the ED with continuous nebulised bronchodilater therapy, oral steroids as well as antibiotics. He starts to improve and on reasessing him clinically, after reviewing (...) his chest X Ray and blood tests you decide to discharge him with community follow up. You wonder whether he should also be started on course of steroids in addition to his antibiotics. Search Strategy COCHRANE LIBRARY Issue 4 2005 Ovid MEDLINE 1966-November 2005 Embase 1980–2005 Week 47 Medline:[{ or exp Pulmonary Disease, Chronic Obstructive or or chronic or exp Bronchitis, Chronic OR or exp EMPHYSEMA/ or exp PULMONARY EMPHYSEMA} AND [{

2006 BestBETS

1652. Review: data are lacking on the effect of bed rest in women with singleton pregnancies who are at high risk of preterm birth Full Text available with Trip Pro

In women with a singleton pregnancy who are at high risk of spontaneous preterm birth, data are lacking to support or refute the effect of bed rest at hospital or at home to prevent preterm birth. Commentary The incidence of preterm birth has stayed constant over the years despite all the advances in medical and social care. A variety of therapies such as bed rest in the lateral position, antibiotics, and uterine tocolytics are often recommended to prevent preterm birth. Bed rest at home may be a more

2006 Evidence-Based Medicine

1653. Continuous subglottic suction is effective for prevention of ventilator associated pneumonia

secretions in this case was an inappropriate indicator of VAP Valles et al, 1995, Spain 190 critically ill general patients requiring mechanical ventilation for >3 days. Randomised to receive continuous aspiration of subglottic secretions (CASS)(n=76) or to receive usual care (n=77) PRCT (level 1b) Duration of ventilation Subglottic suction (CASS) 13±1 day. Control group 11±1 day p>0.02. 64.4% CASS group and 58.4% of control group received an antibiotic agent at the time of randomisation Of 190 patients (...) specimens. No differences in duration of ventilation, hospital stay, or mortality Flawed randomization technique using patient birth year. Onset of VAP CASS patients mean 5.6±2.3 days. Routine care patients mean 2.9±1.2 days; (p=0.006) Pneumatikos et al, 2002, Greece 61 patients admitted to the ICU who were predicted to need ventilation for >5 days. Patients were randomly assigned to receive Selective Decontamination of Subglottic Area (SDSA) using suction and antibiotics (n=30) or placebo (n=31) SDSA

2005 BestBETS

1654. Are routine urine cultures helpful in the management of asymptomatic infants or preschool children with a previous urinary tract infection?

primary and secondary (after a previous UTI) ABU. Despite their weaknesses, which should caution about the generalisation of their findings, these studies have shown that the detection and the treatment of ABU in infants and preschool children did not decrease the risk of renal scarring. In addition, antibiotic-induced modifications of the bacterial flora may increase the risk of acute pyelonephritis, and therefore the risk of cortical damage. Therefore, the practice of routine detection

2005 BestBETS

1655. Review: ear pain and a cloudy, bulging, or distinctly immobile tympanic membrane appear to help diagnose acute otitis media in children Full Text available with Trip Pro

be difficult to teach. One reason why physicians prescribe antimicrobials for children is their assumption of parental expectations of antibiotics. Physicians often overestimate the parents’ expectations, and change in parental expectations does not change physicians’ prescribing behaviour. Providing a contingency plan to parents who expect antibiotics for their children has been shown to improve parental satisfaction without antimicrobial prescription. Thus, parents should not be blamed, and we physicians (...) urgently need to stop over prescribing antimicrobials. References Koivunen P, Alho OP, Uhari M, et al. Minitympanometry in detecting middle ear fluid. J Pediatr 1997 ; 131 : 419 –22. Mangione-Smith R, McGlynn EA, Elliott MN, et al. Parent expectations for antibiotics, physician-parent communication, and satisfaction. Arch Pediatr Adolesc Med 2001 ; 155 : 800 –6. Wheeler JG, Fair M, Simpson PM, et al. Impact of a waiting room videotape message on parent attitudes toward pediatric antibiotic use

2005 Evidence-Based Medicine

1656. Symptoms and signs plus erythrocyte sedimentation rate or C-reactive protein predicted pneumonia in lower respiratory tract infection Full Text available with Trip Pro

with an LRTI. Exclusion criteria included severe clinical disease, recent antibiotic treatment, or hospital admission for respiratory disease. Description of tests: the clinical status of patients (classified as either pneumonia or other LRTI) was based on clinical symptoms and signs, and C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) blood tests. Diagnostic standard: chest radiography (lateral and postero anterior) was used as the diagnostic standard for identifying pneumonia. Outcomes (...) of the 193 antibiotic prescriptions could have been prevented. View this table: Diagnostic characteristics of C reactive protein (CRP) (mg/l) and erythrocyte sedimentation rate (ESR) (mm/h) tests for diagnosing pneumonia in lower respiratory tract infection* CONCLUSIONS In adults with a lower respiratory tract infection, classical symptoms and signs of pneumonia were not predictive of pneumonia. A model consisting of dry cough, diarrhoea, and temperature ⩾38°C plus erythrocyte sedimentation rate or C

2005 Evidence-Based Medicine

1657. Review: adjuvant corticosteroid therapy reduces death, hearing loss, and neurological sequelae in bacterial meningitis Full Text available with Trip Pro

and experts. Study selection and assessment studies in any language were selected if they were randomised controlled trials that compared any type of corticosteroid therapy adjuvant to antibiotics with placebo in patients with ABM and recorded case fatality rates. 2 reviewers independently assessed the quality of studies using the Jadad scale. Outcomes mortality, severe hearing loss (bilateral hearing loss > 60 dB or requiring bilateral hearing aids), and short term (discharge to 6 wk) or long term (6 (...) recent vaccine developments against ABM have shifted the proportion of infections to adults in developed countries, ABM continues to threaten both children and adults in developing countries. Failed treatment of ABM is rarely a bug and drug problem despite recent concerns about drug resistant pneumococci and meningococci. The fact that a host’s immune response causes the bulk of neurological morbidity in ABM (which can be attenuated by adjunctive corticosteroids before administering antibiotics) has

2005 Evidence-Based Medicine

1658. Review: the only effect for surgery plus antiobiotics in vesicoureteric reflux is fewer febrile urinary tract infections Full Text available with Trip Pro

Therapeutics Review: the only effect for surgery plus antiobiotics in vesicoureteric reflux is fewer febrile urinary tract infections Free Steven McTaggart , MD Statistics from Wheeler D, Vimalachandra D, Hodson EM, et al . Antibiotics and surgery for vesicoureteric reflux: a meta-analysis of randomised controlled trials. Arch Dis Child 2003 ; 88 : 688 –94. Q In children with vesicoureteric reflux (VUR), which treatments reduce urinary tract infection (UTI) and renal parenchymal injury (...) ? Clinical impact ratings GP/FP/Primary care ★★★★★★★ METHODS Data sources: Medline, EMBASE/Excerpta Medica (to February 2003), and the Cochrane Controlled Trials Register; reference lists; and contact with authors. Study selection and assessment: randomised (RCTs) or quasi-randomised controlled trials that evaluated surgery (open and closed techniques), antibiotic prophylaxis, non-invasive techniques (eg, management of voiding dysfunction), or any combination of interventions in patients of any age

2005 Evidence-Based Medicine

1659. Are newer macrolides effective in eradicating carriage of pertussis?

to medications unclear. Small study group. Relapse: positive culture at 2 weeks after treatment None in either study or control groups. Comment(s) Antimicrobials are usually administered when Pertussis is suspected or confirmed .If the disease is already established (paroxysmal phase), antibiotics have little or no effect on the clinical course of the illness except to render the patient non infectious to others. This is important, so as to limit the spread of infection especially to the un immunised

2005 BestBETS

1660. Penicillin V did not shorten symptoms in children with sore throat Full Text available with Trip Pro

period: 7 days. Setting: 43 family practices in the Netherlands. Patients: 156 children 4–15 years of age (mean age 10 y, 50% boys) who had a sore throat for <7 days and ⩾2 of 4 Centor criteria (history of fever, absence of cough, swollen tender anterior cervical lymph nodes, and tonsillar exudates). Exclusion criteria: imminent quinsy, scarlet fever, requirement of antibiotics, and intolerance to penicillin. 62% had a positive culture for group A streptococci (GAS). Intervention: PCV7 (n = 46), PCV3

2005 Evidence-Based Medicine

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