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GP Synergy EBM Online Course

The GP Synergy Evidence-Based Medicine and Critical Appraisal Online Course for GP registrars is completed!

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GPET Convention workshop: EBM journal clubs

I ran a workshop on Thursday 8 September 2011, at the GPET 2011 Convention on Evidence-based journal clubs for professional development. The presentation can be viewed online (through prezi.com). A warm thank you to Dr Sjoerd Bruggink for allowing me to use his study published in 2010 for a critical appraisal group exercise.

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Dabigatran versus warfarin for atrial fibrillation

Connolly SJ, et al. Dabigatran versus warfarin in patients with atrial fibrillation. N Engl J Med 2009; 361:1139-1151
Dabigatran (Pradaxa) is non-inferior to warfarin for the prevention of strokes or systemic embolism, in non-valvular atrial fibrillation.

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Type 2 diabetes and increased risk for malaria

Danquah I, et al. Type 2 diabetes mellitus and increased risk for malaria infection. Emerg Inf Dis 2010; 16 (1): 1601-1604
There may be an association between type 2 diabetes and malaria infection.

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Inhaled corticosteroids as rescue treatment

Martinez FD, et al. Use of beclomethasone dipropionate as rescue treatment for mild persistent asthma…. Lancet 2011; 377: 650–57
Inhaled beclomethasone (Qvar) used as rescue therapy with salbutamol is likely better than salbutamol alone, for children with mild persistent asthma who do not take regular inhaled corticosteroids.

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Zinc for the common cold

Singh M, Das RR. Zinc for the common cold. Cochrane Database of Systematic Reviews 2011, Issue 2. Art. No.: CD001364
Zinc administered within 24 hours of the symptoms of a common cold is associated with favourable outcomes but with some side-effects.

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GP Synergy EBM Online Course GPET Convention workshop: EBM journal clubs Dabigatran versus warfarin for atrial fibrillation Type 2 diabetes and increased risk for malaria Inhaled corticosteroids as rescue treatment Zinc for the common cold

Nov
30

GP Synergy EBM Online Course

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I have been working on an online EBM and critical appraisal teaching program for GP registrars at GP Synergy this year.  The online course is finally complete!

This program will take 4-5 hours to complete, but is divided into a number of separate modules. The modules use an online presentation platform, and you will need a modern browser (e.g., Firefox 7+, Chrome 14+, Safari, Internet Explorer 9+) on a Windows PC or Mac. Your computer will need broadband internet access.

This program uses elements from the free online course; Understanding Evidence-Based Healthcare: A Foundation for Action – Course for Physicians, that is developed and maintained by the US Cochrane Center at the Johns Hopkins Bloomberg School of Public Health. Special acknowledgement must go to the Center who gave permission for their course to be used. You should feel free to complete the entire Cochrane Center course if you want more detailed teaching in evidence-based medicine.

The GP Synergy EBM Online Course can be found here: http://tiny.cc/ebm4gp

I welcome any comments that will help improve this teaching resource.

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Sep
11

GPET Convention workshop: EBM journal clubs

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I ran a workshop on Thursday 8 September 2011, at the General Practice Education and Training (GPET) 2011 Convention on Evidence-based journal clubs for professional development.  The presentation can be viewed online (through prezi.com).  A warm thank you to Dr Sjoerd Bruggink for allowing me to use his study published in 2010 for a critical appraisal group exercise. Read the rest of this entry »

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Jun
22

Dabigatran versus warfarin for atrial fibrillation

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Journal reference: Connolly SJ, Ezekowitz MD, Yusuf S, et al. Dabigatran versus warfarin in patients with atrial fibrillation. N Engl J Med 2009; 361:1139-1151 [1]

Link: http://dx.doi.org/10.1056/NEJMoa0905561

Published: 17 September 2009

Evidence cookie says...

 Dabigatran (Pradaxa) is non-inferior to warfarin for the prevention of strokes or systemic embolism, in non-valvular atrial fibrillation. 

Its effectiveness and safety has not been demonstrated in patients with severe renal impairment or active liver disease (excluded).

The benefits (↓ major bleeding and ↓ stroke) from dabigatran should be balanced against the harms (↑ myocardial infarction and ↑ gastrointestinal bleeding).

The study design may have biased results favourably towards dabigatran.

Note: dabigatran is not currently funded by the PBS for this indication.

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May
11

Type 2 diabetes and increased risk for malaria

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Journal reference: Danquah I, Bedu-Addo G, Mockenhaupt F. Type 2 diabetes mellitus and increased risk for malaria infection. Emerg Inf Dis 2010; 16 (1): 1601-1604 [1]

Link: http://dx.doi.org/10.3201/eid1610.100399

Published: October 2010

Evidence cookie says...

 There may be an association between type 2 diabetes and malaria infection. 

The evidence is low in quality and unreliable.

Nevertheless, this finding reinforces current travel advice for travellers to malaria endemic regions (mosquito avoidance, protective clothing, chemoprophylaxis).

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May
04

Inhaled corticosteroids as rescue treatment

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Journal reference: Martinez FD, Chinchilli VM, Morgan WJ, et al. Use of beclomethasone dipropionate as rescue treatment for children with mild persistent asthma (TREXA): a randomised, double-blind, placebo-controlled trial. Lancet 2011; 377: 650–57 [1]

Link: http://dx.doi.org/10.1016/S0140-6736(10)62145-9

Published: 19 February 2011

Evidence cookie says...

 Children with mild persistent asthma should be treated with regular inhaled corticosteroids. 

Treatment with salbutamol (Ventolin) alone significantly increases the risk of exacerbations.

Inhaled beclomethasone (Qvar) used as rescue therapy with salbutamol is likely better than salbutamol alone, for children with mild persistent asthma who do not take regular inhaled corticosteroids.

Note: the study is relatively underpowered.

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Apr
27

Zinc for the common cold

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Journal reference: Singh M, Das RR. Zinc for the common cold. Cochrane Database of Systematic Reviews 2011, Issue 2. Art. No.: CD001364 [1]

Link: http://dx.doi.org/10.1002/14651858.CD001364.pub3

Published: 16 February 2011

Evidence cookie says...

 Zinc administered within 24 hours of the symptoms of a common cold is associated with favourable outcomes but with some side-effects. 

  • ↓ cold symptom duration by ~ 1 day
  • ↓ cold symptom severity (minimal)
  • ↑ side-effects: bad taste (NNH = 7) and nausea (NNH = 12)

It is premature to routinely recommend zinc therapy for the common cold. It is reasonable to direct patients seeking community remedies towards zinc rather than other common treatments (echinacea, vitamin C).

Note: there are limitations to the evidence. See below for more details.

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Apr
20

Statins in primary prevention and all-cause mortality

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Journal reference: Ray KK, Seshasai SR, Erqou S, et al.  Statins and all-cause mortality in high-risk primary prevention: a meta-analysis of 11 randomized controlled trials involving 65 229 participants. Archives of Internal Medicine, 2010; 170(12): 1024-31 [1]

Link: http://archinte.ama-assn.org/cgi/content/abstract/170/12/1024

Published: 28 June 2010

Evidence cookie says...

Statins were not associated with a benefit to all-cause mortality in a primary prevention setting.

Although there is some ambiguity with the data, it is very unlikely that statins are of clinical benefit in patients with low and moderate absolute cardiovascular risk.

Until more definitive evidence becomes available, statins in the primary prevention setting should be reserved for those patients who are at high risk according to the 2005 lipid management guidelines [2]

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Apr
13

Proton pump inhibitors with clopidogrel

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Journal reference: van Boxel OS, van Oijen MGH, Hagenaars MP, et al. Cardiovascular and gastrointestinal outcomes in clopidogrel users on proton pump inhibitors: results of a large Dutch cohort study.  Am J Gastroenterol 2010; 105: 2430–6 [1]

Link: http://dx.doi.org/10.1038/ajg.2010.334

Published: 24 August 2010

Evidence cookie says...

 Concurrent proton pump inhibitors (PPIs) may increase the risk of cardiovascular outcomes in patients taking clopidogrel.

The results of this specific study are likely invalid due to methodological biases (see below for details).

There is substantial uncertainty in the evidence base generally.

GPs should be guided by a precautionary principle:

  • it is reasonable to prescribe PPIs to those with clear indications
  • new and ongoing therapy should be assessed from the perspective that PPIs might increase the risk of harm

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Apr
06

Deaths after chiropractic upper cervical spine manipulation

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Journal reference: Ernst E. Deaths after chiropractic: a review of published cases. Int J Clin Pract, July 2010; 64(8): 1162-5 [1]

Link: http://dx.doi.org/10.1111/j.1742-1241.2010.02352.x

Published: 16 June 2010

Evidence cookie says...

 Chiropractic, specifically, high-velocity, short-lever thrusts of the upper spine with rotation is associated with numerous deaths.

Most of the deaths were secondary to vascular accidents of the vertebrobasilar system.

There is no good evidence for this therapy for any medical condition.

General practitioners should advice their patients considering chiropractic therapy to avoid upper cervical manipulation.

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Mar
30

Diagnostic x-ray and ultrasound and childhood cancer

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Journal reference: Rajaraman P, Simpson J, Neta G, et al. Early life exposure to diagnostic radiation and ultrasound scans and risk of childhood cancer: case-control study. BMJ 2011; 342: d472 [1]

Link: http://dx.doi.org/10.1136/bmj.d472

Published: 10 February 2011

Evidence cookie says...

 The excess risk of childhood cancer from diagnostic imaging in utero and early infancy remains unclear.

This study was underpowered for the results to be meaningful.

Nevertheless, the results suggest that in utero ultrasound is unlikely to be associated with childhood cancer.

Following a precautionary principle, the usual practice of avoiding diagnostic radiation in pregnant women and young children should continue.

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