Less Is More

Simpler & Better Medicine

Single-Dose Oral Dexamethasone Versus Multidose Prednisolone for Acute Exacerbations of Asthma in Children Who Attend the Emergency Department. — June 27, 2017

Single-Dose Oral Dexamethasone Versus Multidose Prednisolone for Acute Exacerbations of Asthma in Children Who Attend the Emergency Department.

Summary: For children with seeking emergency care for an acute exacerbation of asthma, treatment with a single dose of oral dexamethasone (0.3 mg/kg) may be associated with the no differences on the Pediatric Respiratory Assessment Measure (PRAM) score at 4 days compared to treatment with oral prednisolone (1 mg/kg per day for 3 days), but treatment with dexamethasone can be accomplished with fewer doses of medication (once vs daily for 3 days); with dexamethasone associated with lower likelihood of vomiting but a higher likelihood of needing further systemic steroids within 14 days.

https://www.ncbi.nlm.nih.gov/m/pubmed/26460983/

Strength of Recommendation = B

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Lung ultrasound for diagnosis of pneumonia. — February 10, 2017
Long-Term Oxygen for COPD with Moderate Desaturation. — December 6, 2016

Long-Term Oxygen for COPD with Moderate Desaturation.

Summary: For patients with chronic obstructive pulmonary disease (COPD) and moderate resting or exertional oxygen desaturation, an approach of not using supplemental oxygen may be associated with the same life expectancy and the same likelihood of hospitalization or COPD exacerbation as an approach of using supplemental oxygen, without the risks associated with supplemental oxygen use (such as tripping over equipment, fires or burns).

https://www.ncbi.nlm.nih.gov/m/pubmed/27783918/

Strength of Recommendation = B

Effect of Hydrocortisone on Development of Shock Among Patients With Severe Sepsis. — November 15, 2016

Effect of Hydrocortisone on Development of Shock Among Patients With Severe Sepsis.

Summary: For adult patients with severe sepsis (but not in septic shock), an approach of not administering glucocorticoids may be associated with the same risks of developing septic shock and of in-hospital or 28-day mortality as an approach of routinely administering a continuous infusion of hydrocortisone for 5 days, but avoiding routine use of glucocorticoids may be associated with a lower risk of hyperglycemia.

https://www.ncbi.nlm.nih.gov/m/pubmed/27695824/

Strength of Recommendation = B

Effect of Conservative vs Conventional Oxygen Therapy on Mortality Among Patients in an Intensive Care Unit. — October 28, 2016

Effect of Conservative vs Conventional Oxygen Therapy on Mortality Among Patients in an Intensive Care Unit.

Summary: For patients who are expected to spend 72 hours or more in an intensive care unit (ICU), providing supplemental oxygen titrated to a goal Spo2 between 94% and 98% may be associated with lower risk of mortality than providing supplemental oxygen titrated to a goal Spo2 between 97% and 100%.

https://www.ncbi.nlm.nih.gov/m/pubmed/27706466/

Strength of Recommendation = B

 

 

Levosimendan and Acute Organ Dysfunction in Sepsis. — October 26, 2016

Levosimendan and Acute Organ Dysfunction in Sepsis.

Summary: For adults in hospital with sepsis, an approach of avoiding use of levosimendan appears to be associated with a higher likelihood of successful weaning from mechanical ventilation and a lower likelihood of supraventricular tachydysrhythmia than an approach of administering levosimendan for treatment of sepsis.

https://www.ncbi.nlm.nih.gov/m/pubmed/27705084/

Strength of Recommendation = B

Using venous blood gas analysis in the assessment of COPD exacerbation. — September 30, 2016

Using venous blood gas analysis in the assessment of COPD exacerbation.

Summary: For a patient with an acute exacerbation of chronic obstructive pulmonary disease (AECOPD) and an initial pulse-oximetry reading of > 80%, management guided by venous blood gas (if pH > 7.35) may be just as effective as management guided by arterial blood gas sampling but with less patient discomfort. (http://thorax.bmj.com/content/71/3/210/F5.large.jpg)

http://www.ncbi.nlm.nih.gov/m/pubmed/26628461/

Strength of Recommendation = B

 

Duration of Antibiotic Treatment in Community-Acquired Pneumonia. — September 27, 2016

Duration of Antibiotic Treatment in Community-Acquired Pneumonia.

Summary: For adult patients hospitalized with community-acquired pneumonia (CAP), a practice of stopping antibiotics after 5 days’ treatment if the patient has been afebrile for 48 hours and has no more than one sign of clinical instability*, appears to be associated with a shorter overall duration of antibiotic treatment and a lower likelihood of hospital re-admission over the next 30 days (with no worse rates of clinical improvement or symptom improvement) compared to a practice of stopping antibiotics based on the clinical determination or impression of the treating physician.

* – Signs of clinical instability in CAP: Systolic blood pressure  < 90 mm Hg, heart rate >  100/min, respiratory rate > 24 /min,  oxygen saturation < 90%, or Pao2 < 60 mm Hg on room air.

http://www.ncbi.nlm.nih.gov/m/pubmed/27455166/

Strength of Recommendation = B

Effectiveness of N95 respirators versus surgical masks in protecting health care workers — August 30, 2016
Self-monitoring and self-management of oral anticoagulation. — July 19, 2016

Self-monitoring and self-management of oral anticoagulation.

Summary: For patients on oral anticoagulant therapy, self-monitoring and self-management of anticoagulation may lead to a lower likelihood of thromboembolic events compared to standard monitoring and management, and self-management may be associated with a lower risk of all-cause mortality.

http://www.ncbi.nlm.nih.gov/m/pubmed/27378324/

Strength of Recommendation = A

Chest radiographs for acute lower respiratory tract infections. — July 1, 2016

Chest radiographs for acute lower respiratory tract infections.

Summary: For patients (adults or children) presenting with a possible lower respiratory tract infection, management without the use of chest radiography may lead to the same duration of illness and of symptoms as management based on chest radiography findings, but at lower cost and without radiation exposure.

http://www.ncbi.nlm.nih.gov/m/pubmed/24369343/

Strength of Recommendation = B

 

Cost-Effectiveness of Obtaining Blood Cultures in Children Hospitalized for Community-Acquired Pneumonia. — June 24, 2016

Cost-Effectiveness of Obtaining Blood Cultures in Children Hospitalized for Community-Acquired Pneumonia.

Summary: For children hospitalized with pneumonia, obtaining blood cultures only from those children at high risk for bacteremia (compared to obtaining blood cultures from all children hospitalized with pneumonia) might lead to an annual savings of over $3000 per 100 patients.

http://www.ncbi.nlm.nih.gov/m/pubmed/26456740/

Strength of Recommendation = C

Single-Dose Oral Dexamethasone Versus Multidose Prednisolone for Acute Exacerbations of Asthma in Children — June 21, 2016

Single-Dose Oral Dexamethasone Versus Multidose Prednisolone for Acute Exacerbations of Asthma in Children

Summary: For children brought to emergency care for an acute asthma exacerbation, giving single-dose dexamethasone + an inhaled beta-agonist may lead to the same rates of treatment response and hospitalizations as treatment with a 3-day course of prednisolone + an inhaled beta-agonist (although patients given dexamethasone might have a slightly increased need for subsequent oral steroids within the following 2 weeks).

http://www.ncbi.nlm.nih.gov/m/pubmed/26460983/

Strength of Recommendation = B

Outcomes of catheter-directed thrombolysis plus anticoagulation vs anticoagulation alone to treat lower-extremity proximal deep vein thrombosis. — June 14, 2016

Outcomes of catheter-directed thrombolysis plus anticoagulation vs anticoagulation alone to treat lower-extremity proximal deep vein thrombosis.

Summary: For hospitalized patients with deep-vein thrombosis (DVT) of the proximal lower leg or the inferior vena cava, treatment with anticoagulation alone may be associated with lower rates of blood transfusion, pulmonary embolism, and intracranial hemorrhage compared to treatment with anticoagulation + catheter-directed thrombolysis (CDT); and the two procedures appear to be associated with the same risk of in-hospital mortality. (This study also found lower hospital costs and shorter lengths of stay associated with standard anticoagulation alone, compared to anticoagulation + CDT)

http://www.ncbi.nlm.nih.gov/m/pubmed/25047081/

Strength of Recommendation = B

Prescription Strategies in Acute Uncomplicated Respiratory Infections: A Randomized Clinical Trial. — March 11, 2016

Prescription Strategies in Acute Uncomplicated Respiratory Infections: A Randomized Clinical Trial.

Summary: For adults with acute uncomplicated respiratory infections, a delayed-prescription strategy (ie, prescribing an antibiotic with instructions to start the medication only if symptoms get worse) may lead to significantly decreased use of antibiotics, without any clinically significant increase in the duration of severe symptoms compared to patients given immediate antibiotic treatment.

http://www.ncbi.nlm.nih.gov/m/pubmed/26719947/

Strength of Recommendation = B

Effect of Opioids vs NSAIDs and Larger vs Smaller Chest Tube Size on Pain Control and Pleurodesis Efficacy Among Patients With Malignant Pleural Effusion: The TIME1 Randomized Clinical Trial. — February 23, 2016

Effect of Opioids vs NSAIDs and Larger vs Smaller Chest Tube Size on Pain Control and Pleurodesis Efficacy Among Patients With Malignant Pleural Effusion: The TIME1 Randomized Clinical Trial.

Summary: For patients with malignant pleural effusion needing pleurodesis, nonsteroidal anti-inflammatory drugs (NSAIDs) while a chest tube is in place may provide the same analgesic efficacy as opioids, without any increased risk of pleurodesis failure.

http://www.ncbi.nlm.nih.gov/m/pubmed/26720026/

Strength of Recommendation = B

Short-term vs conventional glucocorticoid therapy in acute exacerbations of chronic obstructive pulmonary disease: the REDUCE randomized clinical trial. — February 19, 2016

Short-term vs conventional glucocorticoid therapy in acute exacerbations of chronic obstructive pulmonary disease: the REDUCE randomized clinical trial.

Summary: For patients with acute COPD, and treated at presentation with IV methylprednisolone + a broad-spectrum antibiotic, treatment with a subsequent 5-day course of oral prednisone 40 mg daily works just as well for preventing subsequent COPD exacerbations as a 14 day course of prednisone 40 mg daily, but with a significantly lower overall glucocorticoid exposure.

http://www.ncbi.nlm.nih.gov/m/pubmed/23695200/

Strength of Recommendation = B

Severity assessment tools for predicting mortality in hospitalised patients with community-acquired pneumonia. Systematic review and meta-analysis. — February 2, 2016

Severity assessment tools for predicting mortality in hospitalised patients with community-acquired pneumonia. Systematic review and meta-analysis.

Summary: For patients with pneumonia, the 5 item CURB65 and 4 item CRB65 severity scores perform just as well as the much longer and more complicated Pneumonia Severity Index at predicting low, intermediate or high risk of 30-day mortality, but are much simpler to  use; in addition, the CURB65 and CRB65 scores may perform better than the PSI at predicting which patients are at high risk of 30 day mortality.

http://www.ncbi.nlm.nih.gov/m/pubmed/20729231/

Strength of Recommendation = A

Air Versus Oxygen in ST-Segment-Elevation Myocardial Infarction. — January 29, 2016

Air Versus Oxygen in ST-Segment-Elevation Myocardial Infarction.

Summary: For patients with acute ST-elevation-myocardial infarction (STEMI) who are not hypoxic, avoiding administration of supplemental oxygen may be associated with having a smaller infarct size (as measured by mean peak creatine kinase level and by cardiac MRI 6 months later), a lower rate of recurrent myocardial infarction, and a lower frequency of cardiac dysrhythmia. (In other words, administration of supplemental oxygen to non-hypoxic STEMI patients may lead to a larger infarct size and a higher risk of  dysrhythmia and recurrent infarction)

http://www.ncbi.nlm.nih.gov/m/pubmed/26002889/

Strength of Recommendation = B

Stethoscope versus point-of-care ultrasound in the differential diagnosis of dyspnea: a randomized trial. — January 12, 2016

Stethoscope versus point-of-care ultrasound in the differential diagnosis of dyspnea: a randomized trial.

Summary: For patients with dyspnea, evidence from a small clinical trial suggests that examination with a stethoscope may be just as effective as point-of-care ultrasound for excluding the diagnosis of heart failure, and for making an affirmative diagnosis of pneumonia, at markedy lower cost.

http://www.ncbi.nlm.nih.gov/m/pubmed/25715019/

Strength of Recommendation = B

Outcomes of Basic Versus Advanced Life Support for Out-of-Hospital Medical Emergencies. — December 14, 2015

Outcomes of Basic Versus Advanced Life Support for Out-of-Hospital Medical Emergencies.

Summary: For older patients requiring emergency medical transport, 90-day survival may be higher after treatment with basic life support (BLS) rather than advanced cardiac life support (ACLS) in cases of trauma, stroke, or respiratory failure (although ACLS may be associated with higher likelihood of 90-day survival for acute MI (AMI)); and neurologic function at 90 days may be better with BLS for trauma, stroke, respiratory failure, and AMI.

http://www.ncbi.nlm.nih.gov/m/pubmed/26457627/

Strength of Recommendation = B

Screening for Occult Cancer in Unprovoked Venous Thromboembolism. — November 9, 2015

Screening for Occult Cancer in Unprovoked Venous Thromboembolism.

Summary: For patients with unprovoked venous thromboembolism (VTE), limiting the screening for occult malignancy to a basic history and examination (basic lab testing, chest x-ray, and screening for breast, cervical, and prostate cancer) may work just as well as screening with history, examination and comprehensive computed tomography (CT) of the abdomen and pelvis.

http://www.ncbi.nlm.nih.gov/m/pubmed/26095467/

Strength of Recommendation = B

High-flow oxygen through nasal cannula in acute hypoxemic respiratory failure. — November 2, 2015
Effect of early vs late tracheostomy placement on survival in patients receiving mechanical ventilation: the TracMan randomized trial. — October 30, 2015

Effect of early vs late tracheostomy placement on survival in patients receiving mechanical ventilation: the TracMan randomized trial.

Summary: For hospitalized adult patients requiring mechanical ventilation, tracheostomy within 4 days of critical care admission may not lead to improved 30-day mortality compared to delayed tracheostomy (after 10 days if still indicated).

http://www.ncbi.nlm.nih.gov/m/pubmed/23695482

Strength of Recommendation = B

Effect of Noninvasive Ventilation vs Oxygen Therapy on Mortality Among Immunocompromised Patients With Acute Respiratory Failure: A Randomized Clinical Trial. — October 28, 2015

Effect of Noninvasive Ventilation vs Oxygen Therapy on Mortality Among Immunocompromised Patients With Acute Respiratory Failure: A Randomized Clinical Trial.

Summary: For critically ill immunocompromised adult patients, treatment with non-invasive ventilation may not be any better than treatment with oxygen alone for reducing the risk of mortality, oxygenation failure, or length of ICU or hospital stay.

http://www.ncbi.nlm.nih.gov/m/pubmed/26444879/

Strength of Recommendation = C

Chemotherapy Use, Performance Status, and Quality of Life at the End of Life. — August 20, 2015

Chemotherapy Use, Performance Status, and Quality of Life at the End of Life.

Summary: For patients with end-stage cancer (less than 6 months’ life expectancy) who have good performance status, avoiding late palliative chemotherapy may lead to a better quality of death than if palliative chemotherapy is used. (In other words, the quality of death for patients with end-stage cancer is not improved, and can be harmed, by chemotherapy use near death.)

http://www.ncbi.nlm.nih.gov/m/pubmed/26203912/

Strength of Recommendation = B

Health outcomes of continuous positive airway pressure versus oral appliance treatment for obstructive sleep apnea: a randomized controlled trial. — July 31, 2015

Health outcomes of continuous positive airway pressure versus oral appliance treatment for obstructive sleep apnea: a randomized controlled trial.

Summary: For patients with obstructive sleep apnea, use of a mandibular-advancement device (MAD) rather continuous positive airway pressure (CPAP) may lead to more consistent treatment use and may lead to improved general quality-of-life ratings (however, improvements in disease-oriented measures may be similar with either approach).

http://www.ncbi.nlm.nih.gov/m/pubmed/23413266

Strength of Recommendation = C

Costs and effectiveness of spacer versus nebulizer in young children with moderate and severe acute asthma. — July 7, 2015

Costs and effectiveness of spacer versus nebulizer in young children with moderate and severe acute asthma.

Summary: For children with moderate to severe acute asthma, treatment with albuterol delivered by metered-dose inhaler (MDI) + spacer may lead to a greater reduction in wheezing and a lower likelihood of hospital admission than treatment with albuterol delivered by nebulizer. In this study, treatment with MDI + spacer was preferred over treatment with nebulizer by approximately 85% of children and parents, and the costs of treatment with MDI + spacer were approximately 65% of the costs of treatment with nebulizer.

http://www.ncbi.nlm.nih.gov/m/pubmed/10753248/

Strength of Recommendation = B

Comparing hospice and nonhospice patient survival among patients who die within a three-year window. — July 6, 2015
Randomized trial of salbutamol via metered-dose inhaler with spacer versus nebulizer for acute wheezing in children less than 2 years of age. — July 3, 2015

Randomized trial of salbutamol via metered-dose inhaler with spacer versus nebulizer for acute wheezing in children less than 2 years of age.

Summary: For children under age 2 seen in an emergency department with acute wheezing, giving albuterol (salbutamol) by metered-dose inhaler (MDI) with a spacer and facial mask may lead to faster clinical improvement than giving albuterol by nebulizer (the albuterol dosing in this study was 2 puffs at 100 microg/puff by MDI every 10 min for 5 doses, or 0.25 mg/kg every 13 min for 3 doses by nebulizer).

http://www.ncbi.nlm.nih.gov/m/pubmed/10738013/

Strength of Recommendation = B

Effect of honey, dextromethorphan, and no treatment on nocturnal cough and sleep quality for coughing children and their parents. — June 17, 2015

Effect of honey, dextromethorphan, and no treatment on nocturnal cough and sleep quality for coughing children and their parents.

Summary: For children with night-time cough and difficulties sleeping due to an upper respiratory infection (URI), honey may be the preferred treatment. In a comparison of honey, dextromethorphan, or no treatment for children with URI, parents rated honey most favorably for improving cough, child sleep, and parent sleep.

http://www.ncbi.nlm.nih.gov/m/pubmed/18056558

Strength of Recommendation = B

Systematic review of randomized controlled trials examining written action plans in children: what is the plan? — June 16, 2015
Written action plans for asthma in children. —

Written action plans for asthma in children.

Summary: For children with asthma, use of an asthma-action plan (AAP) that is based on symptoms may lead to a lower risk of acute care visits than use of an (AAP) based on peak-flow (PF) measurements, and may be more acceptable to patients (although a PF based AAP may lead to a greater reduction in the number of symptomatic days per week).

http://www.ncbi.nlm.nih.gov/m/pubmed/16856090/

Strength of Recommendation = A

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