Clinical Inquiries, 2018
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Item Does amniotomy shorten spontaneous labor or improve outcomes?(Family Physicians Inquiries Network, 2018) Worthley, Megan; Kelsberg, Gary; Safranek, SarahQ: Does amniotomy shorten spontaneous labor or improve outcomes? Evidence-based answer: No. Amniotomy neither shortens spontaneous labor nor improves any of the following outcomes: length of first stage of labor, cesarean section rate, maternal satisfaction with childbirth, or Apgar score <7 at 5 minutes (strength of recommendation [SOR]: A, large metaanalyses of randomized controlled trials [RCTs] and a single RCT with conflicting results). Amniotomy does result in about a 55% reduction of pitocin use in multiparous women, a small (5 minutes) decrease in the duration of second-stage labor in primiparous women, and about a 50% overall reduction in dysfunctional labor -- ie, no progress in cervical dilation in 2 hours or ineffective uterine contractions (SOR: A, large meta-analyses of RCTs and a single RCT with conflicting results). Amniotomy doesn't improve other maternal outcomes--instrumented vaginal birth; pain relief; postpartum hemorrhage; serious morbidity or death; umbilical cord prolapse; cesarean section for fetal distress, prolonged labor, antepartum hemorrhage--nor fetal outcomes-- serious neonatal morbidity or perinatal death; neonatal admission to intensive care; abnormal fetal heart rate tracing in first-stage labor; meconium aspiration; or fetal acidosis (SOR: A, large meta-analyses of RCTs and a single RCT with onflicting results).Item What medical therapies work for gastroparesis?(Family Physicians Inquiries Network, 2018) Wells, Orion; Warcola, Ashley; Neher, Jon; Safranek, SarahQ: What medical therapies work for gastroparesis? Evidence-based answer: It's unclear if there are any highly effective medications for gastroparesis (TABLE1-10). Metoclopramide improves the sense of fullness by about 40% for as long as 3 weeks, may improve nausea, and doesn't affect vomiting or anorexia (strength of recommendation [SOR]: B, small randomized controlled trial [RCT]). Whether or not erythromycin has an effect on symptoms is unclear (SOR: C, conflicting trials and expert opinion). Domperidone may improve quality of life (by 2%) for as long as a year, but its effect on symptoms is also unclear (SOR: C, small RCTs). Cisapride may not be effective for symptom relief (SOR: C, small conflicting RCTs), and levosulpiride is likely similar to cisapride (SOR: C, single small crossover trial). Nortriptyline (SOR: B, single RCT) and intrapyloric botulinum toxin A (SOR: B, small RCT and crossover trial) aren't effective for symptom relief.Item What's the best VTE treatment for patients with cancer?(Family Physicians Inquiries Network, 2018) Pham, Thuy; Sundquist, Hannah; Kelsberg, Gary; Safranek, SarahQ: What's the best VTE treatment for patients with cancer? Evidence-based answer: No. Head-to-head studies directly compare all the main treatments for venous thromboembolism (VTE) in cancer patients. Long-term treatment (3-12 months) with low-molecular-weight heparin (LMWH) reduces recurrence of VTE by 40% compared with vitamin K antagonists (VKA), but doesn't change rates of mortality, major or minor bleeding, or intracranial hemorrhage in patients with solid or hematologic cancer at any stage or in any age group. Initial treatment with LMWH reduces mortality by 30% compared with unfractionated heparin (UFH) for 5 to 10 days followed by warfarin, but doesn't alter recurrent VTE or bleeding. Non-vitamin K oral anticoagulants (NOACs) have risks of recurrent VTE or VTE-related death (composite outcome) and clinically significant bleeding comparable to VKA or LMWH/VKA (strength of recommendation [SOR]: B, meta-analyses of randomized controlled trials [RCTs], mostly of low quality).Item How effectively do ACE inhibitors and ARBs prevent migraines?(Family Physicians Inquiries Network, 2018) Morris, Brendan; Neher, Jon; Safranek, SarahQ: How effectively do ACE inhibitors and ARBs prevent migraines? Evidence-based answer: The angiotensin-converting enzyme (ACE) inhibitor lisinopril reduces the number of migraines by about 1.5 per month in patients experiencing 2 to 6 migraines monthly (strength of recommendation [SOR]: B, small cross-over trial); the angiotensin II receptor blocker (ARB) candesartan may produce a similar reduction (SOR: C, conflicting crossover trials). Considered as a group, ACE inhibitors and ARBs have a moderate to large effect on the frequency of migraine headaches (SOR: B, meta-analysis of small clinical trials), although only lisinopril and candesartan show fair to good evidence of efficacy. Providers may consider lisinopril or candesartan for migraine prevention, taking into account their effect on other medical conditions (SOR: C, expert opinion).Item Do statins alter the risk or progression of dementia?(Family Physicians Inquiries Network, 2018) Tang, Tess; Clifton, Jospeh; Neher, Jon; Safranek, SarahQ: Do statins alter the risk or progression of dementia? Evidence-based answer: No. Moderate-intensity statin therapy (with pravastatin or simvastatin) doesn't prevent progression to dementia in patients at increased risk. No prevention studies address high-intensity statin therapy (strength of recommendation [SOR]: A, randomized controlled trials [RCTs]). Neither moderate- nor high-intensity statin therapy (with simvastatin or atorvastatin, respectively) improves existing mild to moderately severe Alzheimer's or vascular dementia (SOR: A, RCTs). Although statin use is associated with a mild, rare, reversible delirium, it isn't linked to permanent cognitive decline (SOR: C, expert opinion).