Tools for evidence based practice
Post updated 3/9/2023
References:
USPSTF Guideline 2018 Osteoporosis Screening
USPSTF Guideline 2018 Calcium + Vitamin D
Tools For Practice: Tool for screening for osteoporosis
Tools For Practice: Bisphosphonate duration
Choosing wisely: Repeat BMD interval
Essential Evidence Audio POEM: No need to monitor BMD after treatment
Pills and Creams
Topical NSAIDs have the similar pain effectiveness for chronic MSK pain as oral NSAIDs but the side-effect profile is equivalent to placebo. Reference
All NSAIDs decrease pain for knee and hip OA but NSAIDS are more effective. Paracetamol (acetaminophen) least effective. Reference
Paracetamol (acetaminophen) no better than placebo for pain, perhaps effective for tension headaches. Reference
Glucosamine has been extensively studied and there is NO reliable improvement in pain or function. Reference
Tramadol and opioids are effective for short-term (3-6 months) osteoarthritis pain compared to placebo but have higher side effects. Reference
Duloxetine reduces pain in patients with osteoarthritis (NTT=5), the most common side effects are gastrointestinal. Reference
Side effects
NSAIDs and COX-2 increase the risk of major vascular events and death. Naproxen and low dose ibuprofen < =1200mg appear to be an exception and preferred. Reference
Standard-dose NSAIDs do not seem to cause progression in patients with CKD with a GFR of 30-90 mL/min. Reference
Celecoxib 200mg BID combined with esomeprazole 20mg BID in patients with prior NSAID induced GI bleeding in one RCT had a 0% chance of recurrent ulcer bleeding. Reference
Injections and Exercise
Viscosupplementation with Hyaluronan and Hylan decrease osteoarthritis knee pain and improves function. This effect last longer than intra-articular steroids. Reference
Intra-articular corticosteroids improve pain by about 20% for 1-3 weeks in patients with knee osteoarthritis. Reference
Intra-articular corticosteroids vs saline no difference in pain after routine injection every 3 months and resulted in some reduction in cartilage by MRI. Reference
Land-based exercise reduce knee pain and improve function. Reference
May 18, 2021 the USPSTF expanded colorectal cancer screening to start at age 45. For age over 75, they recommend it be offered selectively after considering various factors. They continue to recommended all methods of colorectal cancer screening including in no particular order:
High-sensitivity fecal occult blood test or fecal immunochemical test yearly
Stool DNA-FIT
Computed tomography colonography every 5 years
Flexible sigmoidoscopy every 5 years
Flexible sigmoidoscopy every 10 years + annual FIT
Colonoscopy screening every 10 years
The USPSTF on 3/9/2021 has updated and expanded their indications for screening for lung cancer with low dose CT to include ages 50 to 80 and those who have a 20 or more pack year history of smoking. Those who are currently smoking or quit in the last 15 years qualify for screening. GRADE B
The USPSTF recommends screening all adults aged 18 to 79 for Hepatitis C. This is a one time screening for most adults unless they have new or ongoing risk factors.
REF: USPSTF
In a RCT of 156 patients with knee OA, mean age 56, physical therapy was superior to corticosteroid injections in reducing symptoms on the WOMAC score after 1 year by 33.7%. There were no serious complications from PT or injections aside from one patient fainted during the injection procedure. The patients received from 1 to 3 injections over the study period or 8 to 11 physical therapy sessions. Cost were similar in both groups.
Reference Article: https://www.nejm.org/doi/full/10.1056/NEJMoa1905877
A Tools for Practice review of the Roth Score found that there are inaccuracies with the stated sensitivity and specificity. An alternative BMJ visual summary includes a multiple step process and typically assessed red flag symptoms.
The ADA in November of 2019 recommends against the routine use of oral antibiotics in immunocompetent adults for management of most pulpal/periapical related dental pain and intraoral swelling. They advised the patient should seek care with a dentist for local management and treat the pain with NSAIDs and acetaminophen. There is a clincal pathway which can be used to aid in the clinical decision for antibiotics.
Ref: JADA 11/2019
It should be noted this guideline addresses the treatment only for patients in the Untied States without recent travel who are immunocompetent adults.
Diagnosis:
Gram stain and culture of respiratory secretions AND blood cultures for:
Hospitalized patients with severe CAP table 1, empiric treatment for MRSA/P. aeruginosa , prior infection with of MRSA/P. aeruginosa, or IV antibiotics in last 90 days (overall very low quality evidence).
Legionella urinary antigen
In the case of an outbreak , recent travel, or severe CAP (conditional recommendation, low quality evidence)
Influenza nucleic acid amplification
When influenza is circulating in the community (Strong recommendation, mod quality evidence)
Treatment:
Outpatient vs Inpatient
Clinical prediction tools, PSI(Pneumonia Severity Index) preferred over the CURB-65, should be used with clinical judgement to help determine inpatient vs outpatient treatment (conditional recommendation, low quality evidence).
Outpatient antibiotic selection is detailed in table 3.
Coverage is expanded if a patient is consider high risk. High risk patients are those with comorbidities including: chronic heart, ling, liver, or renal disease, diabetes, alcoholism, malignancy or asplenia.
Inpatient antibiotic selection is detailed in table 4.
Coverage is dependent on severity table 1 of illness and is expanded for patients with prior respiratory isolation of MRSA, p. aeruginosa.
Influenza treatment with oseltamivir should be started in patients with confirmed CAP and influenza positive regardless of timing of diagnosis. They should also be treated with antibiotics.
Duration of treatment should be continued until the reach clinical stability and no less than 5 days. Clinical stability should be defined by a validated measure including resolution of vital sign abnormalities, ability to eat, and normal mentation. MRSA and P. aeruginosa treatment should be 7 days.
The IDSA makes recommendations against:
The CDC has made the final recommendation for the PCV 13 vaccine. It is no longer routinely recommend for patients age 65 or older. After shared decision making patients over 65 can choose to receive the vaccine. It continues to be recommended for those patients 19 and older with CSF leak, cochlear implants, and immunocompromising conditions.
FMEBM - Family Medicine Evidence Based Medicine 
