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171581. What evidence is there that 5 days antibiotic treatment for chest infections is superior to 3 days.

that antibiotics are unlikely to be advantageous in non-pneumatic LRTI. The NLH Q&A Service answered a similar question in April 2005 [1] where we used the SIGN guidelines on the community management of lower respiratory track infection in adults [2]. This reported: “Several randomised controlled trials and a number of meta-analyses and systematic reviews have investigated the treatment of non-pneumonic LRTI in the community and have shown that antibiotic treatment of non-pneumonic LRTI leads to no or minimal

2006 TRIP Answers

171582. In patients with ulcerative colitis who are on long term mesalazine treatment, should renal function be checked on a regular basis?

? We could find no definitive answer to your question. The British Society of Gastroenterology have a guideline on inflammatory bowel disease in adults [1], which includes the following passage: “Mesalazine intolerance occurs in up to 15%. Diarrhoea (3%), headache (2%), nausea (2%), and rash (1%) are reported, but a systematic review has confirmed that all new 5-ASA agents are safe, with adverse events that are similar to placebo for mesalazine or olsalazine. No comparison between balsalazide

2006 TRIP Answers

171583. What is the standard daily dose of St john's wort which should be recommended for a patient with mild depression and for how long would it need to be taken before an improvement could be expected?

is the standard daily dose of St john's wort which should be recommended for a patient with mild depression and for how long would it need to be taken before an improvement could be expected? One of the major criticisms levelled at complementary and alternative therapies is the lack of standardisation of preparations. As the Cochrane Systematic Review, ‘St John's Wort for depression’, reported [1]: “As the preparations available on the market might vary considerably in their pharmaceutical quality (...) , the results of this review apply only to the products tested in the included studies.” The NICE guideline on depression [2] states: “Although there is evidence that St John’s wort may be of benefit in mild or moderate depression, healthcare professionals should not prescribe or advise its use by patients because of uncertainty about appropriate doses, variation in the nature of preparations and potential serious interactions with other drugs (including oral ontraceptives, anticoagulants

2006 TRIP Answers

171584. Is there evidence that atypical antipsychotics increase cardiovascular mortality compared to standard antipsychotics?

concerning atypical antipsychotics and their ability to increase cardiovascular mortality compared to typical (conventional) antipsychotic agents. A HTA systematic review of atypical antipsychotic drugs compared, “ The clinical effectiveness, safety and cost-effectiveness of ‘atypical’ antipsychotic drugs in schizophrenia were compared with conventional antipsychotic drugs, placebo and other atypical antipsychotic drugs.” In terms of cardiotoxic events, the review reported: “At least two atypical (...) conventional antipsychotics. " [ 6] References 1. A-M Bagnall, L Jones and L Ginnelly et al. A systematic review of antipsychotic drugs in schizophrenia. 2003. ( ). 2. Liperoti R, Gambassi G and Lapane K et al. Conventional and atypical antipsychotics and the risk of hospitalization for ventricular arrhythmias or cardiac arrest. Arch Intern Med. 2005 Mar 28;165(6):696-701. ( ). 3. Enger C, Weatherby L and Reynolds R et al. Serious cardiovascular events and mortality among patients with schizophrenia. J

2006 TRIP Answers

171585. Regarding GP Appraisals, is there and evidence or reseach about the effectivness of "360 degree feedback"?

) Department of Trade and Industry. 36- Degree Feedback: Best Practice Guidelines. (Accessed 11/04/06). 4) Lockyer, J PhD. “Multisource feedback in the assessment of physician competencies.” Journal of Continuing Education in the Health Professions, Winter 2003; 23(1): 4-12. 5) Smitter, J., London, M., Reilly, R. “Does performance improve following multisource feedback? A theoretical model, meta-analysis and review of empirical findings.” Personnel Psychology Spring 2005; 58(1): 33-66. Answered 14 April (...) unlikely that a 360 degree scheme would be accepted where there is no history of systematic feedback on performance. It would present too radical a step.” (3) The BMA guide (1) states that peer review and 360 degree feedback would not work within dysfunctional departments or general practices. In addition to the aforementioned importance of implementation, the literature specific to physician appraisals found 360 degree feedback to be, “one of the better tools that may be adopted and implemented

2006 TRIP Answers

171586. Are there any papers on leg elevation post op and the incidence of dvt?

the prevention of DVT in post-operative patients. These may be of some interest. The Cochrane Library published a systematic review in 2000 examining the use of compression stockings for the prevention of deep vein thrombosis in immobilised hospital patients. They compared studies of graduated compression stockings alone and studies of graduated compression stockings used on a background of any other DVT prophylactic method. “A total of 16 RCTs were identified. GCS were applied on the day before surgery (...) of Systematic Reviews 2000, Issue 1. 2) Handoll HHG, Farrar MJ, McBirnie J, Tytherleigh-Strong G, Milne AA, Gillespie WJ. Heparin, low molecular weight heparin and physical methods for preventing deep vein thrombosis and pulmonary embolism following surgery for hip fractures. The Cochrane Database of Systematic Reviews 2002, Issue 4 Answered 12 April 2006 Follow us: © 2019 Trip Database Ltd. company number 04316414. Trip is proud to be made in the UK.

2006 TRIP Answers

171587. Is it appropriate to use both an ACE and an ARB for the treatment of CCF?

that patients have had their ACE inhibitor dose optimised and have been considered for treatment with a â-blocker and/or spironolactone before this unlicensed option is considered.” A more recent meta-analysis examining ACE or ARBs or ACE/ARB combination chronic heart failure and high-risk acute myocardial infarction and reviewed by DARE [3] stated: “No significant difference was found between combinations of ARB and ACE inhibitors and ACE inhibitors alone for all-cause mortality (OR 0.97, 95% CI: 0.87 (...) of treatment for heart failure where there is good evidence whilst more trial evidence is awaited.” Clinical Evidence also comment on the combination [5] reporting on two systematic reviews. The first systematic review is the same as discussed in reference 3 (above). With regard to the second systematic review Clinical Evidence state: “The review found that angiotensin II receptor blockers plus angiotensin converting enzyme inhibitors significantly reduced the combined outcome of morbidity and mortality

2006 TRIP Answers

171588. What evidence is there for the effectiveness of self-help treatments for anxiety and depression?

interventions in anxiety and depression. In 2005, Anderson et al undertook a systematic review and meta-analysis of self-help books for depression and concluded: “There are a number of self-help books for the treatment of depression readily available. For the majority, there is little direct evidence for their effectiveness. There is weak evidence that suggests that bibliotherapy, based on a cognitive behavioural therapy approach is useful for some people when they are given some additional guidance. More (...) self-help versus waiting list control in the management of anxiety and depression in a randomised controlled trial involving 114 patients. In terms of results, the research team reported: “Adherence to the guided self-help intervention was acceptable and patients reported satisfaction with the intervention. However, there were no statistically significant differences between groups in anxiety and depression symptoms at 3 months.” [5] Finally, van Boeijen undertook a systematic review [6 randomised

2006 TRIP Answers

171589. In a 80 yr old patient with severe pain related to an osteoporotic spinal fracture is there anything, apart from using conventional analgesics, that is effective in reducing pain?

et al undertook a systematic review of five placebo-controlled randomised trials and reported: “ The combined results from five randomized controlled trials, involving 246 patients, determined that calcitonin significantly reduced the severity of pain using a visual analogue scale following diagnosis. Pain at rest was reduced as early as 1 week into treatment (weighted mean difference [WMD] =3.08; 95% confidence interval [CI]: 2.64, 3.52) and this effect continued weekly to 4 weeks (WMD =4.03; 95 (...) information sheet on PV and percutaneous kyphoplasty which discusses indications for procedures, the procedure itself and potential adverse effects. [9] References 1. Knopp J, Diner B and Blitz M et al. Calcitonin for treating acute pain of osteoporotic vertebral compression fractures: a systematic review of randomized, controlled trials. Osteoporos Int. 2005 Oct;16(10):1281-90. Epub 2004 Dec 22. ( ). 2. Blau L and Hoehns J. Analgesic efficacy of calcitonin for vertebral fracture pain. Ann Pharmacother

2006 TRIP Answers

171590. In a 80 yr old patient with severe pain related to an osteoporotic spinal fracture is there anything, apart from using conventional analgesics, that is effective in reducing pain?

et al undertook a systematic review of five placebo-controlled randomised trials and reported: “ The combined results from five randomized controlled trials, involving 246 patients, determined that calcitonin significantly reduced the severity of pain using a visual analogue scale following diagnosis. Pain at rest was reduced as early as 1 week into treatment (weighted mean difference [WMD] =3.08; 95% confidence interval [CI]: 2.64, 3.52) and this effect continued weekly to 4 weeks (WMD =4.03; 95 (...) information sheet on PV and percutaneous kyphoplasty which discusses indications for procedures, the procedure itself and potential adverse effects. [9] References 1. Knopp J, Diner B and Blitz M et al. Calcitonin for treating acute pain of osteoporotic vertebral compression fractures: a systematic review of randomized, controlled trials. Osteoporos Int. 2005 Oct;16(10):1281-90. Epub 2004 Dec 22. ( ). 2. Blau L and Hoehns J. Analgesic efficacy of calcitonin for vertebral fracture pain. Ann Pharmacother

2006 TRIP Answers

171591. A 2 year old with slightly asymetrical skull has been told he has plagiocephaly. Parents want something doing about it. What can be done, if anything, to correct his skull asymetry?

) treatment. Limited to nonsyndromic deformational plagiocephaly, molding helmets serve an important role in the correction of cranial deformities. Customized molding helmets are an adjunct to preventive measures such as frequent posture change. Helmets must be worn 23 h/d until age 1 year. Early intervention is important because molding therapy is not very effective after age 1 year.” [1] In a systematic review of conservative interventions for positional plagiocephaly, Bialocerkowski et al concluded (...) for positional plagiocephaly: a systematic review. Dev Med Child Neurol. 2005 Aug;47(8):563-70. ( ) 3. Loveday BP and de Chalain TB. Active counterpositioning or orthotic device to treat positional plagiocephaly? J Craniofac Surg. 2001 Jul;12(4):308-13. ( ). 4. Institute for Clinical Systems Improvement. Cranial orthoses for deformational plagiocephaly. Bloomington, MN: Institute for Clinical Systems Improvement (ICSI), 2004. ( ). Answered 21 April 2006 Follow us: © 2019 Trip Database Ltd. company number

2006 TRIP Answers

171592. Compared to other medical treatments how effective, if at all, are progestogens in treating menorrhagia, either alone or in combination?

or in combination? This area has a number of recent reviews. Given the number of reviews we have restricted our answer to a chapter from Clinical Evidence and a PRODIGY guideline. The Clinical Evidence chapter on menorrhagia was published in 2004 [1] and discusses three types of progesterone treatments: Intrauterine progestogens – Rated ‘Unknown effectiveness’ “We found no RCTs comparing intrauterine progestogens versus placebo. RCTs identified by several systematic reviews provided insufficient evidence (...) to compare intrauterine progestogens versus other drugs. RCTs identified by two systematic reviews provided insufficient evidence to compare intrauterine versus oral progestogens. One systematic review found that intrauterine progestogens were less effective than hysterectomy or endometrial destruction in reducing menstrual blood loss over 1 year, but caused fewer serious adverse effects than hysterectomy.” Oral progestogens (longer cycle) – Rated ‘Unlikely to be beneficial’ Oral progestogens in luteal

2006 TRIP Answers

171593. A recent learning module from the BMJ suggested that calcium supplementation be used first line in the management of PMT - is there any evidence for this, and if so, what dose?

substantially decrease symptoms of PMS. Calcium supplementation must be taken for 3 months to achieve a treatment effect. Calcium supplementation might have secondary benefits in preventing osteoporosis.” A Clinical Evidence review [3] classed dietary supplements as having ‘Unknown effectiveness’, stating: “One systematic review found insufficient evidence on the effects of calcium and magnesium supplements versus placebo in women with premenstrual syndrome” “The systematic review (2 RCTs, 557 women) found

2006 TRIP Answers

171594. 1) Is there any evidence to prove that electronic blood pressure machines are as accurate as the mercury machines? 2) Can yoga reduce blood pressure?

a worthwhile reduction in BP. Structured interventions to reduce stress (stress management, meditation, yoga, cognitive therapies, breathing exercises and biofeedback) have been shown to result in short term reductions in BP but the interventions studied have been so varied, it is difficult to be prescriptive with regard to an effective strategy.” [5] A systematic review comparing lifestyle intervention to drugs for treating hypertension identified six trials, one of which examined the effectiveness (...) , Resnick L and Hollenberg S. Assessment of sequential same arm agreement of blood pressure measurements by a CVProfilor DO-2020 versus a Baumanometer mercury sphygmomanometer. Blood Press Monit. 2001 Jun;6(3):149-52.( ). 5. British Hypertension Society guideline. 2004. ( ) 6. Nicolson D J, Dickinson H O, Campbell F, Mason J M. Lifestyle interventions or drugs for patients with essential hypertension: a systematic review. Journal of Hypertension, 2004;22(11):2043-2048. ( 7. Murugesan R, Govindarajulu N

2006 TRIP Answers

171595. Is there good evidence for emergency thrombolysis treatment in acute arterial thrombotic stroke?

in the NINDS trial (NINDS rt-PA Study Group, 1995).” [2] An evidence-based technology assessment published by the Agency for Healthcare Research and Quality (AHRQ) notes: “ IV thrombolysis with tPA is effective and efficacious for acute ischemic stroke within 3 hours of symptom onset. The effectiveness is strongly linked to time since onset of symptoms with shorter times demonstrating significantly better outcomes. Patient level meta-analysis suggests that treatment may be effective up to 270 minutes (...) . Although no clinical trial data are available on the use of tPA after 3 hours in patients with vertebrobasilar ishemic disease, case reports have documented good recovery with both intravenous and intra-arterial therapy given as late as 6-12 hours after symptoms onset in selected patients. Clinical expertise is required however, no recommendations can be provided at this time regarding this delayed use of thrombolytic therapy.” [5] Finally, a Cochrane systematic review by Wardlaw et al concluded

2006 TRIP Answers

171596. Is there evidence of added benefit for dipyridamole in addition to aspirin after thrombotic stroke?

/TIA risk and not MI or vascular death, and there have been some concerns over the design of the trial. In addition, systematic reviews in patients at high risk of vascular events have found no benefit from adding dipyridamole to aspirin on important vascular outcomes (e.g. stroke) when ESPS-2 was excluded. This might be due to differences between new and old formulations of dipyridamole. Results from the large, ongoing European and Australian Stroke Prevention in Reversible Ischaemia Trial (ESPRIT (...) ) are awaited to clarify this issue.” [3] The ESPRIT trial is scheduled to be completed by June 2008. [4] Leonardi-Bee et al performed a meta-analysis of dipyridamole for preventing recurrent ischaemic stroke and other vascular events using individual patient data. The authors report: “ Individual patient data were merged from 5 of 7 relevant trials involving 11 459 patients. Results were adjusted for age, gender, qualifying event, and history of previous hypertension. RESULTS: Recurrent stroke was reduced

2006 TRIP Answers

171597. Are all PPI's very similar in efficacy? Am I right to recommend the most cost effective PPi for uncomplicated Dyspepsia?

of PPI should be based on the principles of the 'STEPS' acronym: safety, tolerability, effectiveness, price and simplicity of use. Table 1 shows the usual daily doses of PPIs to treat symptoms of dyspepsia. An analysis of four RCTs in oesophagitis for the NICE guideline found no evidence that one PPI is more effective than another when compared at appropriate, equivalent doses. Similarly, a meta-analysis of 25 RCTs (n>11,000) found no significant differences between equivalent doses of PPIs (...) another, we can simply report the literature we find. In the case of this question we found a number of pertinent secondary review articles. A 2002 WeMeRec document on PPIs in primary care [1], stated: “The choice of PPI is likely to depend on licensed indications and cost, because differences between the PPIs in clinical efficacy and safety are minimal.” They later discuss, at length which PPI, summarising the section with: “In summary, there is currently no clear evidence to suggest that any

2006 TRIP Answers

171598. The asteroid trial using rosuvastatin showed a regression in atherosclerosis. Are there any other trials to show this effect with a statin?

objectives were to assess the effects on both low and high density lipoprotein cholesterol levels (LDL-C and HDL-C). Overall, whilst the results from this preliminary study look promising, the authors' are right to highlight the need for further randomised controlled trials to determine the effect of the observed changes on clinical outcomes.” They also identify further evidence that is not yet published but may be of interest: “There were two related systematic reviews which are currently being (...) completed identified on the Cochrane Database of Systematic Reviews (CDSR) and six reviews identified on the Database of Abstracts of Reviews of Effects (DARE).” Below is a link to the JAMA publication by Dr Nissen et al (3), and the editorial from the same edition (4), which says: “Current data suggest that the predominant benefit derived from statins is through stabilization of lipid-laden plaques, rather than regression of atherosclerosis.” References 1. Kastelein, J. J. P. et al. “Comparison

2006 TRIP Answers

171599. In a patient aged 32 with intravaginal ejaculation time of less than 1 minute, where non-pharmacological treatments have failed, what is the most effective and safe treatment (daily vs as required) to

@tripdatabase.com In a patient aged 32 with intravaginal ejaculation time of less than 1 minute, where non-pharmacological treatments have failed, what is the most effective and safe treatment (daily vs as required) to improve ejaculatory times? In 2004 Bandolier carried out a review of a systematic review [1]. A 2004 guideline, published by the American Urological Association [2], includes the following statement: “Premature ejaculation can be treated effectively with several serotonin reuptake inhibitors (...) (SRIs) or with topical anesthetics. The optimal treatment choice should be based on both physician judgment and patient preference. (Based on Panel consensus and review of data.)” We have also looked for randomised controlled trials published since mid-2004. We will report these briefly below (see reference section for URLs to abstracts, which we recommend you read). We have not assessed these trials for bias. Title: On-demand treatment of premature ejaculation with clomipramine and paroxetine

2006 TRIP Answers

171600. Is there any evidence that more than 1 semen sample is necessary after vasectomy? why the traditional 3?

.” The overall recommendation from RCOG being: “Men should be advised to use effective contraception until azoospermia has been confirmed. The way in which azoospermia is confirmed will depend upon local protocols.” A 2005 article in the Journal of Urology [2], appears to have been based on a 2003 systematic review carried out by the Royal Australasian College of Surgeons [3]. The 2005 paper concludes: “The evidence supports a PVSA (post-vasectomy semen analysis) protocol with 1 test showing azoospermia (...) protocol (which actuall appears on page 33). References 1) RCOG. Male and Female Sterilisation. 2004 ( ) 2) Griffin T et al. How little is enough? The evidence for post-vasectomy testing. J Urol. 2005 Jul;174(1):29-36. ( ) 3) ASERNIP-S. Post-Vasectomy Testing to Confirm Sterility: A Systematic Review. 2003 ( ) Answered 7 April 2006 Follow us: © 2019 Trip Database Ltd. company number 04316414. Trip is proud to be made in the UK.

2006 TRIP Answers

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