Magnesium for leg cramps…just as good as placebo?

Clinical question: does magnesium work for leg cramps?

Findings 1: Cochrane review, 2012

Both magnesium & placebo reduce the frequency of leg cramps with a non-significant difference between the two groups.  The Cochrane review analysed four RCTs (n=322), two of which were deemed to have a high risk of bias and the remaining two trials had a combined total of 86 participants – better quality evidence needed.

Findings 2: Roguin Moar et al. JAMA, 2017

Continue reading “Magnesium for leg cramps…just as good as placebo?”

Q. Is bed rest an effective treatment for anything?

  • Meta-analysis on 39 randomised control trials for 15 different conditions (5777 patients)

Following a medical procedure: Out 24 RCTs-No outcomes improved significantly

  • 8 worsened significantly in some procedures
  • Lumbar puncture – vertigo, nausea and vomiting (no significant improvement in headache)
  • Spinal anaesthesia – headache, back pain
  • Radiculography – headache, nausea,vomiting, dizziness
  • Cardiac catheterisation – haematoma,pain, bleeding

As a treatment Out of 19 RCTs-No outcomes improved significantly

  • 9 worsened significantly for some conditions
  • Acute low back pain – disability (day 1, day 7 and day 28), normal activity, pain
  • Labour – length of stay, contraction frequency, assisted delivery, anaglesia required, APGAR score
  • Proteiunuric hypertension during pregnancy – plasma urea and urate, premonitory symptoms of eclampsia
  • Myocardial infarction – VTE, mortality, non-fatal reinfarction, ischaemia or congestive cardiac failure
  • Acute infection hepatitis – time to recovery

A. There is no evidence that bed rest has any significant beneficial effect when used as a treatment or following a procedure. In some disorders, it seems to be harmful.

Even Short-term Oral Steroids Carry Serious Risk

Short term use of oral corticosteroids and related harms among adults in the United States: population based cohort study
BMJ 2017; 357 doi: https://doi.org/10.1136/bmj.j1415 (Published 12 April 2017)Cite this as: BMJ 2017;357:j1415

Cohort study of more than 1.5 million adults 30 days of initiating these drugs, even at relatively low doses, users had:

  • a nearly 2x increased risk for fracture
  • 3x risk for VTE and
  • 5xrisk for sepsis
  • > one in five adults included in the Clinformatics DataMart, a large national database of commercial insurance claims, received prescriptions for short-term oral corticosteroids during the 3-year study, which ran from January 1, 2012, to December 31, 2014.
  • Of 1,548,945 adults aged 18 to 64 years included in the database, 327,452 (21.1%) received at least one outpatient prescription for short-term oral corticosteroids (30 or fewer days). The mean age of users was 45.5 years (standard deviation [SD], 11.6 years) compared with 44.1 years (SD, 12.2 years) for nonusers (P < .001). The median duration of use was 6 days (interquartile range, 6 – 12 days).
  • The six most common indications for the drugs were upper respiratory tract infections, spinal conditions, intervertebral disc disorders, allergies, bronchitis, and nonbronchitic lower respiratory tract disorders.
  • Within 30 days of drug initiation, there was an increase in incidence rate of the following: sepsis, with a rate ratio of 5.30 (95% CI, 3.80 – 7.41); venous thromboembolism, with a rate ratio of 3.33 (95% CI, 2.78 – 3.99); and fracture, with a rate ratio of 1.87 (95% CI, 1.69 – 2.07).
  • Rate ratios decreased during the following subsequent 31 to 90 days, however.
  • Recommendation: prescribing the smallest possible amount of corticosteroids for treating the condition in question. “If there are alternatives to steroids, we should be use those when possible,”

Smoking cessation: Is abrupt quitting more effective than a gradual approach?

Lindson-Hawley N, Banting M, West R, Michie S, Shinkins B, Aveyard P. Gradual versus abrupt smoking cessation. A randomized, controlled noninferiority trial. Ann Intern Med 2016;164(9):585-592.

  • Patients in the “abrupt cessation group” were asked to stop smoking on their quit day. Participants in the “gradual cessation group” were also given short-acting nicotine products (gum, lozenges, nasal spray, sublingual tablets, inhalator, or mouth spray) and asked to reduce smoking to half of the baseline amount by the end of the first week and to a quarter of the baseline amount at the end of the second week.
  • At both 1 month and 6 months, validated abstinence rates were higher in the abrupt cessation group: 49.0% vs 39.2% at 1 month (relative risk [RR] 0.80; 95% CI 0.66 to 0.93) and 22.0% vs 15.5% (RR 0.71; 0.46 to 0.91) at 6 months.
  • At 1 month, one additional patient will be successful for every 13 patients who abruptly stop instead of stopping gradually (number needed to treat [NNT] = 12.8; 7.5 – 38.4). At 6 months, the benefit is not quite as large (NNT = 22.2; 11.9 – 71.7).

A. For motivated patients, quitting abruptly on a set date, preceded by 2 weeks of nicotine replacement via a patch, is more effective than doing the same preparation but gradually cutting down before stopping, even when each omitted cigarette is replaced with a hit of nicotine.

What is the best duration for nicotine replacement therapy?

 

  • —525 smokers enrolled.
  • —Randomized groups for nicotine replacement via patch at 8, 24, 52 weeks
  • —6 month cessation rates were significantly higher if patches used for 24 wks. vs 8 wks.
  • —No adverse effects noted
  • —Cost effective benefit long term.
  • —No additional therapeutic advantage with long term treatment (up to 52 weeks)
  • —Worsened adherence after 24 weeks
  • —Likely difficulties adhering to patch treatment for such a long period of time.

A.

  • 24 week duration of treatment is best.
  • —Suggested use of Champix (varencicline tartrate) or combination nicotine replacement therapy for better results.

POEM 16.03.17

Q. How do I treat resistant Mycoplasma Genitalium?

›Management of Mycoplasma genitalium infections – can we hit a moving target? BMC Infect Dis. 2015

Review and meta-analysis of 19 studies

  • Azithromycin standard single dose failure (40%)
  • No randomised controlled trial has compared azithromycin 1 g single dose with extended azithromycin 5 days, observational studies report microbiological cure rates of 81 and 88 % respectively.
  • In controlled clinical trials, the microbiological cure rate for doxycycline has ranged between 22 % and 45 %
  • Treatment failures have recently been reported in up to 30 % of patients treated with moxifloxacin
  • treatment with pristinamycin 1 g four times daily for 10 days is currently the only third or fourth line antimicrobial treatment that is available it is not licensed for use within Australia.

A. With some difficulty.

  • ›Do not screen asymptomatic
  • ›Extended course of Azithromycin 500mg plus 250mg 5/7
  • ›Doxycycline 100mg BD for 14 days
  • ›Moxifloxacin 400mg daily for 10 days

POEM 15.03.17

 

Q How well can we predict the risk of developing asthma in preschool children?

A simple asthma prediction tool for preschool children with wheeze or cough.  J Allergy Clin Immunol. 2014

  • 10 predictors with total score between 0 -15: sex, age, wheeze without colds, wheeze frequency, activity disturbance, shortness of breath, exercise-related and aeroallergen-related wheeze/cough, eczema, and parental history of asthma/bronchitis
  • 1226 symptomatic children, 345 (28%) had asthma 5 years later
  • 840 (69%) children were at low risk (score <5)  16% with asthma at school age
  • 288 (23%) were at medium risk (score >6 and <9) 48% with asthma at school age
  • 98 (8%) were at high risk (score >10) 79% with asthma at school age

A. with Sensitivity 72%  Specificity 71%

link to the tool

POEM 14.03.17

Patient Oriented Evidence that Matters

Q. Is it ok to give droperidol to this psychotic gentleman?
The Safety and Effectiveness of Droperidol for Sedation of Acute Behavioral Disturbance in the Emergency Department. Ann Emerg Med. 2015 

1403 patients 10mg droperidol IM,

  • IV Mean time to sedation 20mins
  • Additional dosing required in 31%
  • No increased risk QT prolongation
  • Adverse events 5%,
  • oversedation 8%

“Of the 8 patients with airway obstruction, 6 required a nasopharyngeal airway or jaw thrust briefly, 1 was repositioned on the side, and 1 was intubated but had taken a tricyclic antidepressant overdose.”

A. Yes

  • Droperidol, 10mg, is safe and effective both IM and IV
  • Should be restrained within about 20mins
  • Basic airway maneuvers may be needed
  • No concerns about getting ECGs prior

POEM 10.03.17

Patient Oriented Evidence that Matters

Q. Low dose Perindopril…whats the point?

RAS inhibitors’ dose-dependent efficacy: myth or reality?[Curr Med Res Opin. 2015]

Perindopril is the only ACE inhibitor to show a real dose-response curve for BP decrease. While the effectiveness of RAS blockers on target organ damage is dose dependent and at least partially unrelated to BP control, there is evidence that the only way to obtain a beneficial effect is to use them at full dose.

A. Go hard and recheck renal function in 8 weeks.

POEM 03.03.17

Patient Orientated Evidence that Matters

Do I need to wake up my Anaesthetist to perform a procedural sedation?

Intra-articular lignocaine (IAL) versus intravenous analgesia with or without sedation (IVAS) for manual reduction of acute anterior shoulder dislocation in adults.

First published: 13 April 2011

Authors Conclusions: We observed no significant difference between IAL and IVAS with regard to the immediate success rate of reduction, pain during reduction, post-reduction pain relief and reduction failure. Compared to IVAS, IAL may be less expensive and may be associated with fewer adverse effects and a shorter recovery time.

Ill let him sleep and get back to bed sooner myself.