Top POEMs of 2015: Miscellaneous

Top 20 POEMs of 2015

Some New Regimens Slightly More Effective For H. Pylori Eradication

Clinical question
What is the best treatment regimen for eradication of Helicobacter pylori?

Bottom line
All treatment regimens to eradicate Helicobacter pylori are fairly effective. The 3 regimens that are at least 90% effective are: (1) 7 to 14 days of a proton pump inhibitor (PPI) plus amoxicillin plus clarithromycin plus metronidazole/tinadazole (90%-94% eradication), (2) 10 to 14 days of standard triple therapy plus probiotics (90%), and (3) 10 to 14 days of PPI plus levofloxacin plus another antibiotic (90%). (LOE = 1a)(www.essentialevidenceplus.com)

Reference
Li BZ, Threapleton DE, Wang JY, et al. Comparative effectiveness and tolerance of treatments for Helicobacter pylori: systematic review and network meta-analysis. BMJ 2015;351:h4052.

Study design: Meta-analysis (randomized controlled trials)

Funding source: Government

Setting: Various (meta-analysis)

Synopsis
To perform this systematic review, the authors searched 3 databases, including the Cochrane Library, to find randomized controlled trials published in any language. Although H. pylori was only discovered in 1982, the authors identified a whopping 15,565 studies evaluating treatments to eradicate it. From these, the authors identified 143 studies comparing 14 kinds of treatment versus standard triple treatment [PPI plus clarithromycin plus metronidazole or amoxicillin]. Three researchers independently selected articles for inclusion and 2 authors independently extracted the data and assessed the study quality. The studies, as is usually the case, were of varying quality, though more than half of them were not double-blinded. Also, they were conducted in countries around the world where antibiotic resistance rates may differ from your local patterns. Trying to make sense of these data gets a little tricky so the authors did the analysis 2 ways: they performed meta-analyses, where possible, comparing one treatment regimen to another, and they used a Bayesian network analysis to rank the relative benefit of one regimen against another even when they weren't directly compared. All regimens are effective, though 3 had higher rates of eradication: 7 to 14 days of PPI plus amoxicillin plus clarithromycin plus metronidazole/tinadazole (90%-94% eradication), 10 to 14 days of standard triple therapy plus probiotics (90%), and 10 to 14 days of PPI plus levofloxacin plus another antibiotic (90%). All treatments were tolerated.

Allen F. Shaughnessy, PharmD, MMedEd
Professor of Family Medicine
Tufts University
Boston, MA

Sterile Gloves Not Necessary for Minor Skin Surgery

Clinical question
Do sterile gloves yield lower wound infection rates than clean nonsterile gloves during minor skin surgery?

Bottom line
Infection rates in patients undergoing uncomplicated minor skin surgery were not different when sterile gloves, rather than simply clean gloves, were worn. A previous study (Perelman VS, et al. Ann Emerg Med 2004;43:362-370) similarly found no difference in infection rates between sterile and nonsterile gloves in patients undergoing uncomplicated laceration repair in the emergency department. (LOE = 1b)(www.essentialevidenceplus.com)

Reference
Heal C, Sriharan S, Buttner PG, Kimber D. Comparing non-sterile with sterile gloves for minor surgery: a prospective randomised controlled non-inferiority trial. Med J Aust 2015;202(1):27-32.

Study design: Randomized controlled trial (single-blinded)

Funding source: Industry

Allocation: Concealed

Setting: Outpatient (primary care)

Synopsis
These investigators enrolled 493 consecutive patients presenting to a general practice in Australia for minor skin excisions. Exclusion criteria included needing skin flaps, excision of a sebaceous cyst, and a history of latex allergy. Eligible patients randomly received (concealed allocation assignment) treatment by physicians wearing either sterilized gloves or standard, boxed, nonsterilized gloves to perform the excision. Treating physicians were aware of the type of gloves they were wearing, and it is possible that they were more scrupulous with cleaning when wearing the nonsterile gloves. Follow-up was performed by a physician or nurse masked to treatment group assignment, with only 3% of cases lost. Using intention-to-treat analysis, infection occurred in 9.3% of patients treated with sterile gloves and 8.7% of patients treated with nonsterile gloves, a nonsignificant difference. The study was 80% powered as a noninferiority trial to detect a 7% difference in infection rates, if one existed.

David Slawson, MD
Director of Information Sciences
University of Virginia Health System
Charlottesville, VA

Duration of Vasomotor Symptoms Can Be Quite Long During Menopause

Clinical question
How long can women expect the vasomotor symptoms associated with menopause to last?

Bottom line
Vasomotor symptoms last a median 7.4 years in women progressing through menopause. Women who begin to have frequent symptoms early (during premenopause or perimenopause) will experience symptoms for a median of 11.8 years, including 9.4 years after their final menstrual period. African-American women will experience vasomotor symptoms longer (median 10.1 years), but symptoms disappear more quickly in Japanese and Chinese women (median ~5 years). (LOE = 1b)(www.essentialevidenceplus.com)

Reference
Avis NE, Crawford SL, Greendale G, et al, for the Study of Women's Health Across the Nation (SWAN). Duration of menopausal vasomotor symptoms over the menopause transition. JAMA Intern Med. 2015;175(4):531-539.

Study design: Cohort (prospective)

Setting: Population-based

Synopsis
These investigators enrolled 1449 women identified at 7 sites across the United States. The women were between the ages of 42 and 52 years, reported a menstrual cycle in the 3 months before screening, and were not taking oral contraceptives or hormone therapy. The women were followed up for 13 years. The median duration of vasomotor symptoms was 7.4 years for all women. Women who were premenopausal or early perimenopausal when they first reported frequent vasomotor symptoms (occurring on at least 6 days over 2 weeks) had a median duration of more than 11.8 years, including a median 9.4 years following their final menstrual period. Some women continued to have symptoms at the end of the 13 years of study. Women who were postmenopausal at the onset of vasomotor symptoms experience these symptoms for a median 3.4 years. African-American women reported the longest total duration (median 10.1 years) and Japanese and Chinese women had the shortest total durations (median 4.8 - 5.4 years). For the 881 women for whom a final menstrual period could be determined, the median duration was 4.5 years following this final menstrual period. Perceived stress and depressive symptoms were associated with an increase in vasomotor symptom duration (hazard ratio 0.75 and 0.66, respectively).

Allen F. Shaughnessy, PharmD, MMedEd
Professor of Family Medicine
Tufts University
Boston, MA

POEMs are provided by Essential Evidence Plus, a point-of-care clinical decision support system published by Wiley-Blackwell. For more information, please see http://www.essentialevidenceplus.com(www.essentialevidenceplus.com).

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