Clinical Inquiries, 2002
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Item When should patients with asymptomatic aortic stenosis be evaluated for valve replacement?(Family Physicians Inquiries Network, 2002) Colen, Michelle; Lindbloom, Erik; Meadows, Susan E.For patients whose echocardiograms show advanced calcification of the aortic valves, a jet velocity of > 4.0 m/s, or a progression in jet velocity of 0.3m/s/year; and for patients who have an abnormal exercise response or an impaired functional status, consider referral for valve replacement prior to the onset of symptoms (Grade of Recommendation: C).Item When should acute nonvenereal conjunctivitis be treated with topical antibiotics?(Family Physicians Inquiries Network, 2002) Kane, Kevin Y.; Meadows, Susan E.; Ellis, Mark R.Children with suspected or culture-proven acute nonvenereal bacterial conjunctivitis should be treated with topical antibiotics, which hastens clinical and microbiological remission and may prevent potentially serious morbidity. In light of recent evidence regarding the self-limiting nature of conjunctivitis in adults and the development of antibiotic resistance, a "wait-and-see"� approach with careful follow-up may be reasonable for adults, but this approach has not been evaluated. (Grade of recommendation: C, based on extrapolation from systematic reviews of specialty clinic trials and cohort studies.)Item What is the best way to evaluate acute diarrhea?(Family Physicians Inquiries Network, 2002) Montgomery, Lynda; Scoville, CarynLimited evidence delineates the relative probabilities of causes of acute diarrhea, typically defined as a diarrheal disease lasting 14 days or fewer, in the developed world. Viruses (rotavirus, Norwalk, and other enteric viruses) are responsible for most cases. Stool culture helps to identify bacterial causes (Salmonella, Shigella, enterotoxic Escherichia coli), especially in patients with fever and bloody stool. A modified 3-day rule (eg, performing only Clostridium difficile toxin tests on low-risk patients who have been hospitalized for 3 or more days) leads to a more rational use of stool cultures without missing cases of clinically significant disease. (Grade of recommendation: D, based on limited studies, reliance on expert opinion, and consensus.)Item What is the best treatment for impacted cerumen?(Family Physicians Inquiries Network, 2002) Wilson, Stephen A.; Scoville, CarynDocusate sodium given 15 minutes before irrigation is most effective for facilitating cerumen removal during a single office visit. (Grade of recommendation: B, based on head-to-head trials that lacked irrigationonly arms.) Treatment with 5% urea hydrogen peroxide in glycerol is most effective for facilitating cerumen removal between office visits, reducing the amount of irrigation needed. (Grade of recommendation: B-, based on lack of rigorous randomization, lack of definition of cerumen impaction, and only one placebo-controlled trial.) No trials recommending one strategy over another exist.Item What is the most effective treatment for acute low back pain?(Family Physicians Inquiries Network, 2002) Harwood, Marc I.; St. Anna, LeilaniNonsteroidal anti-inflammatory drugs (NSAIDs) are more effective than placebo for pain relief in patients with acute low back pain (grade of recommendation: A). There is no consistent evidence that NSAIDs are more effective than acetaminophen (grade: D). Muscle relaxants are effective for short-term relief of acute low back pain (grade: A), but there is no added benefit when they are used in combination with NSAIDs (grade: B). Advice to remain active speeds recovery compared with short-term bed rest (grade: A). There is no consistent evidence that epidural steroid injections are effective for acute low back pain (grade: D). Spinal manipulation or back exercises are no more effective than medications alone (grade: B).