New, True & Poo. Faculty/Presenter Disclosure

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1 New, True & Poo Unpleasant Truths Comforting Lies Tina, Mike K, Adrienne, Mike A, Evidence & CPD Program, Alberta College of Family Physicians Department of Family Medicine, University of Alberta Faculty/Presenter Disclosure Faculty/Presenter: Mike Allan, Mike Kolber & Tina Korownyk Where we get Personal $: U of A, Alberta Health Faculty/Presenter: Adrienne Lindblad (ACFP salary) Where we get Grant/ Program $: Alberta College of Family Physicians, Other Colleges of Family Physicians, Toward Optimized Practice, Other non profit organizer Relationships with commercial interests: Grants/Research Support: Not applicable Speakers Bureau/Honoraria: Not applicable Consulting Fees: Not applicable Other: None 1

2 What s New What s True What s Poo Quirks Survey: 203 pts & 151 docs regarding good care Choose Wisely needs to look at more than docs. Category Patients Doctors Tension Headache, no CT 36% 82% Explain risk of CT 51% 64% Second Opinion for CT 30% 5% URTI, no antibiotic 66% 95% Explain CPG against Abx 81% 95% Primary Care Workload : 101,818,352 visits (2007 vs 14) Annual visits per patients 4.7 to 5.2 Telephone doubled and 5% increase in office (which 90% of contacts) Time per visit was 8.65 minutes and now is 9.22 minutes. Overall: workload increased 16% in 7 years. JAMA Intern Med Aug 1;176(8): Lancet Jun 4;387(10035):

3 MK Medication Expiratory Dates Expiration dates: ~1 5 years post production California Pharmacy found 8 meds (15 compounds) expired for years. Analyzed 14 compounds: 1 pain, sedative 3 tablets tested x 3Xs 12/14 tested compounds: >90% labeled potency US Military SLEP program: 88% of 122 meds tested retained potency 1year (average extension 6 years) Exceptions: Nitroglycerin, insulins, some Abx Bottom Line: keep using your (slightly) expired meds ARCH INTERN MED 2012; 172 (21), DrugSafety Information forpatientsandproviders AL Vitamin D, Big doses and Falls RCT: 200 Swiss pts, mean 78yrs, previous fall, 67% female, & 58% had Vitamin D <50 nmol/l, x1yr Oral: 24,000 IU, 60,000 IU or 24,000 IU + 300μg of calcifediol (per month) Outcome: Vitamin rose 30, 45 and 65 nmol/l High Dose: no improved Physical function tests Fallers ( 1 fall): 48% low dose, 66 67% high dose, NNH 6 Mean # of falls: 0.94, 1.47 and 1.24 (p=0.09) Bottom Line: High dose vitamin D is potentially dangerous in seniors. (Third study to show) Bischoff Ferrari. JAMA Intern Med. 2016;176(2):. doi: /jamainternmed

4 TK Duration of Antibiotics RCT 312 hospitalized for pneumonia. All 5 d of Abx. If temp 37.8 x 48hours and 1 pneumonia instability Sx Outcome: median Abx use was 5 vs 10 d. Symptom Resolution day 10: 56% vs 49%. Similar later. Readmission by day 30 1% vs 7%. No diff mean days to improvement (12 d), X ray resolution, length hospital stay & mortality. Bottom Line: Antibiotic duration can be guided by symptoms (not arbitrary durations). Uranga. JAMA Intern Med doi: /jamainternmed TFP update 4

5 MK Medication for Passing Renal Stones TFP #18. help pass stones by 28 days (NNT 4) Largest RCT, 1167 pts, ureteric stone <10 mm Nifedipine (SR) 30mg, tamsulosin 0.4mg or placebo OD x4 wks Outcome: No difference between groups All the same: Spontaneous stone passage (~80%), Time to stone passage, analgesic use, or self reported health status In stones >5 mm: 71% tamsulosin vs 61% placebo (p=0.13). Stopping for adverse events: nifedipine (NNH=10) & tamsulosin (NNH=25). Bottom Line: Best evidence indicates that nifedipine does not help pass renal stones. Furthermore, there is real doubt if alpha blockers like tamsulosin provide any benefit (except perhaps in stones >5mm). TFP #18 (1 st : January 18, 2010). Lancet 2015;386: Health Technol Assess 2015;19(63). SPRINT: BP targets (TFP 37) RCT: 9361 pts, target <140 vs <120. Age 50, BP 140 Higher risk pts: 17% CVD, mean Framingham 20%, Stopped early. Outcome: 121 vs 136 mmhg at 3.26 yrs, meds 2.8 vs 1.8 CVD: 5.2% vs 6.8%, HR 0.75 ( ), NNT 61 Death: 3.3% vs 4.5%, HR 0.73 ( ), NNT 90, Harms: Hypotension 3.4% vs 2%, syncope 3.5% vs 2.4%, electrolyte 3.8% vs 2.8%, Acute kidney injury/failure 4.4% vs 2.6% Important Caveats Subgroups same: Age 75 (2636 pts) & Others (Gender, Race, CKD) Exclusion: Ejection fraction <35%, Diabetes, Past stroke, egfr<20, standing BP at 1 min <110 Bottom Line: Strong evidence to lower BP targets in higher risk patients (not diabetics this time). No clear that helpful for kidneys? N Engl J Med 2015; 373:

6 The Pharmaceutical Graveyard H o p e AL Changing Dietary Fats to Live Longer RCT: Minnesota Coronary Experiment (MCE) , follow up 3 yrs, 2355 pts, age 52, 53% male, vegetable oil (n 6 linoleic acid via corn, replace saturated fat Outcome: Cholesterol down 14% (0.8 mmol/l) vs 1% Recovered survival analysis: No effect (if anything, trend to harm, particularly age 65) Partial data with autopsy (on MI): 41% diet vs 22% control Meta analysis (5 RCTs, 10,808 pts): of actual diet (not advice) CHD death = hazard ratio 1.13 (0.83 to 1.54) Bottom Line: No RCT support dietary modification of fats intake to improve CVD or death. Ramsden. BMJ 2016;353:i1246 6

7 COPD: LABA + LAMA vs LABA +steroid RCT: 3362 pts (age 65, 76% male, FEV 44%) x 1 yr. Indacaterol (110 μg) + glycopyrronium (50 μg) OD vs salmeterol (50 μg) + fluticasone (500 μg) Outcome: Rate of mod severe exacerbation: 0.98 vs 1.19, rate ratio 0.83 ( ) Time to mod severe exacerbation: 127d vs 87d, HR 0.78 ( ) SGRQ ~1.3 better with LABA+LAMA (0 100, 4 MCID) pneumonia was 3.2% vs 4.8% ss Bottom Line: LABA + LAMA seems to be slightly better combination than LABA + steroids. N Engl J Med Jun 9;374(23): TK Hydrating Kids: Electrolyte solution? RCT 647 kids (mean 28 months, 51% male, 68% score 0 and 25% score 1 2 out of 8), daily f/u ½ strength apple juice vs apple flavored, sweetened Pediatric Electrolyte, each 2L given 5mL q2 5 minutes Outcomes: Tx failure 17% vs 25%, NNT ~12. Mostly less return to care, hospitalization & IV rehydration Rehydration equal if <24 months, 24 months ½ AJ better Bottom line: For kids with minimal dehydration, ½ strength AJ (or preferred fluids) as good as electrolyte solution. JAMA. 2016;315(18):

8 RESEARCH MK 5 Second Rule Dropped foods: 4 inoculated surfaces (steel, tile, wood, carpet), measured bacteria transfer Contact time, food and surface type effected all bacteria transfer (watermelon, carpet ) Coliform count on different household sites: Surface Coliforms / inch 2 Toilet Seat 0.68 Kitchen Floor 2.75 Fridge Handle or Kitchen counter ~6 Toilet flush handle 34 Kitchen rag or sponge 20,000,000 Bottom Line: Wash your rags! Appl. Environ. Microbiol. doi: /aem Carroll A, New York Times Oct 12, 2016, Journal of Applied Microbiology 1998, 85: 819 8

9 Incompetent & unaware: Linked by Necessity 4 studies: humour, logic, grammar/reflection) & logic/training (Done university students) Outcomes: Bottom quartile estimated their ability ~65 percentile (above average). Showing others work only did not help bottom quartile self assess. Only training helped self assess. Bottom Line: If you are bad at something, you don t know it. Ignorance more frequently begets confidence than does knowledge J Pers Soc Psychol Dec;77(6): TK 9 studies (but discussed many others) Testing: hand grip strength, mental health, blood samples, etc If sex is within 2 hours before competition High quality, randomized controlled studies are urgently needed. 9

10 More Illumination to Follow 10