Do SSRIs and SNRIs reduce the frequency and/or severity of hot flashes in menopausal women.

CLINICAL QUESTION: In menopausal women who experience regular hot flashes, does treatment with selective serotonin reuptake inhibitors (SSRIs) or serotonin-norepinephrine reuptake inhibitors (SNRIs) reduce the frequency and/or severity of hot flashes? ANSWER: Yes. Review of the literature suggests that treatment with SSRIs or SNRIs reduces the frequency and severity of hot flashes in menopausal and post-menopausal women. Studies demonstrated that paroxetine (Paxil), citalopram (Celexa) and escitolapram (Lexapro) were the most effective SSRIs, and venlafaxine (Effexor) was the most effective first line SNRI, with desvenlafaxine as a second option. The most common side effects reported for both SSRIs and SNRIs are nausea and constipation, with most resolving within the first week of treatment. SNRIs have been associated with increased blood pressure in some patients and should be used with caution in women with hypertension. Women with a history of breast cancer and taking tamoxifen should avoid SSRIs, which have been shown to interfere with tamoxifen metabolism. SNRIs are the safest drugs for this population. Treatment choice should be patient-specific and begin with the lowest dose available. LEVEL OF EVIDENCE FOR THE ANSWER: A. SEARCH TERMS: SSRI, SNRI, hot flashes, vasomotor symptoms, menopause. SEARCH CONDUCTED: August 2014, February 2016 and August 2016. INCLUSION CRITERIA: menopausal, perimenopausal or postmenopausal women 18 years of age or older with frequent and/or severe vasomotor symptoms, meta-analyses, systematic reviews, randomized controlled trials, cohort studies. EXCLUSION CRITERIA: pre-menopause, anxiety, depression, panic disorder, bipolar disorder, co-morbid conditions.

Yoga and other meditative movement therapies to reduce chronic pain.

CLINICAL QUESTION: In adults with chronic pain, do yoga and other meditative movement therapies to improvement in chronic pain symptoms? ANSWER: Yes. However, in each of the studies reviewed, yoga classes were included as part of the pain management regime, sometimes alone and sometimes in tandem with DVDs or audiotapes. We feel that no exercise therapy program should be undertaken without professional coaching from certified, registered and qualified instructors. DATE ANSWER WAS DETERMINED: August 2014, June, 2015, August 2015. LEVEL OF EVIDENCE FOR THE ANSWER: A. SEARCH TERMS: chronic pain, yoga, exercise therapy, meditative movement therapy. INCLUSION CRITERIA: Adults; meta-analyses; systematic reviews; cohort studies; randomized controlled trials; practice guidelines; articles from 2010 to present. EXCLUSION CRITERIA: Children younger than 18 years of age, Pilates.

Can Bedside Ultrasound Inferior Vena Cava Measurements Accurately Diagnose Congestive Heart Failure in the Emergency Department? A Clin-IQ.

Congestive heart failure (CHF) is a major cause of morbidity and mortality. Early diagnosis of CHF in patients presenting to the emergency department (ED) with undifferentiated dyspnea would allow clinicians to begin appropriate treatment more promptly. Current guidelines recommend B-type natriuretic peptide (BNP) levels for more accurate diagnosis of CHF in dyspneic patients. Although BNP levels are relatively inexpensive, the test is not usually performed at bedside and results may take up to an hour or more. BNP may also have a "gray zone" in which the values can neither confirm nor rule out CHF. BNP has a reported sensitivity of 87% and specificity of 74% at a cutoff of 400 pg/ml. Studies investigating the sensitivity and specificity of bedside ultrasound (US) inferior vena cava (IVC) measurements for identifying CHF report a specificity of 84% to 96% and sensitivity values ranging from 37% to 93%, depending on the study. Given that US IVC measurements are performed at bedside and results are available rapidly, it is reasonable to evaluate whether US IVC measurements, taken by appropriately trained ED clinicians, alone or in combination with BNP, may increase diagnostic accuracy of congestive heart failure.

Clinical Question: Nasal saline or intranasal corticosteroids to treat allergic rhinitis in children.

CLINICAL QUESTION: In pediatric populations, is nasal saline irrigation as effective as intranasal corticosteroids at relieving allergic rhinitis symptoms? ANSWER: No. Intranasal steroids are more effective than nasal saline alone to reduce symptoms of allergic rhinitis (AR) in children. Combination therapy further improves symptom reduction. LEVEL OF EVIDENCE FOR THE ANSWER: B SEARCH TERMS: Allergic Rhinitis, Nasal Saline, Nasal corticosteroids, children younger than age 18. DATE SEARCH WAS CONDUCTED: August and September 2014, October 2015. INCLUSION CRITERIA: Meta-analyses, randomized controlled trials, systematic reviews, cohort studies, nasal spray, hypertonic saline solution, nasal lavage, rhinitis, intranasal administration, nasal saline, human, English language. EXCLUSION CRITERIA: Antihistamines, Adults, Articles older than 2008.

What Are the Recommended Timing and Screening Modalities in Women at Higher Risk for Developing Breast Cancer? A Clin-IQ.

Early detection of breast cancer is desirable to prevent progression to advanced disease. This subject has been one of significant study and debate for women at normal risk, and recommendations continue to evolve. However, with regard to women at high risk, the recommendations from various health care professional organizations, including the recent recommendations from the United States Preventative Services Task Force, are different and also inconsistent concerning when to begin screening and which modalities should be used. We review several randomized controlled trials and consensus opinions regarding when to begin screening for breast cancer and how to best screen women at high risk. Specifically, we address women with known personal history of breast cancer, prior mantle radiation, or specific family history (including genetic family history) of breast cancer. The purpose of this inquiry is to present current evidence and suggest a clinical pathway regarding the screening of women at high risk for breast cancer.

Orthotics Compared to Conventional Therapy and Other Non-Surgical Treatments for Plantar Fasciitis.

CLINICAL QUESTION: In adults with acute plantar fasciitis whose symptoms have not been relieved with the conventional regimen of NSAIDS, stretching and lifestyle modification, do the addition of orthotics (prefabricated or custom fitted) reduce pain and improve function compared with other non-surgical treatments (manipulative chiropractic, physical therapy and/or heel steroid injections)? ANSWER: Yes. Studies have shown that orthotics, both prefabricated and custom fitted, reduce pain and improve function in adults with acute plantar fasciitis with few risks or side effects. Used alone or in addition to conventional therapy (NSAIDs, stretching, lifestyle modification), orthotics are effective and well tolerated by patients for short-term pain relief and improved function. Prefabricated orthotics are less costly and provide similar relief to more expensive custom orthotics. Level of Evidence of the Answer: A Search Terms: Plantar fasciitis, heel pain, treatment, orthotics, Limits: Adult, human, English, Review, Randomized-Control Trials, Systematic Reviews, adults age 18 or more, publication dates 2004 to present. Date Search was Conducted: January 16, 2014; updated January 20, 2015 INCLUSION CRITERIA: Recent published systematic reviews, randomized controlled, meta-analyses; adults with confirmed acute or recent diagnosis of plantar fasciitis. EXCLUSION CRITERIA: Studies older than 10 years, children, adolescents less than 18 years of age, chronic or recalcitrant plantar fasciitis.

In adult smokers unwilling or unable to quit, does changing from tobacco cigarettes to electronic cigarettes decrease the incidence of negative health effects associated with smoking tobacco? A Clin-IQ.

Data from a randomized controlled trial and systematic review support the claim that switching from tobacco cigarettes to electronic cigarettes (e-cigarettes) can reduce the short-term negative health effects of smoking. In adult smokers unwilling or unable to quit, exhaled carbon monoxide levels, total number of cigarettes smoked, and exposure to nitrosamine chemicals were reduced within a 12-month period. While the electronic cigarette industry remains largely unregulated thus far, these studies provide encouraging hope in the uphill battle toward helping patients make informed and healthy choices.

Are at-home sleep studies performed using portable monitors (PMs) as effective at diagnosing obstructive sleep apnea (OSA) in adults as sleep laboratory-based polysomnography (PSG)?

UNLABELLED: RESIDENCY PROGRAM: University of Oklahoma Health Sciences Center, Department of Family and Preventive Medicine, Oklahoma City, OK. ANSWER: In patients with suspected OSA, it is reasonable to use PMs if the patient has a high pretest probability (based on an Epworth Sleepiness Scale (ESS) ≥10 and clinical symptoms*) without significant co-morbid heart disease or other sleep disorders and he/she is able to prove competency in setting up the home equipment properly without assistance. However, if the patient has a negative PM, it is standard to perform PSG as it appears approximately 20% will have a false negative PM. (*Clinical symptoms include snoring, witnessed apneas, obesity, pulmonary hypertension, refractory hypertension, morning headaches, increased neck circumference-->17 inches in men, >16 inches in women--daytime sleepiness.) LEVEL OF EVIDENCE FOR THE ANSWER: A. SEARCH TERMS: obstructive sleep apnea, polysomnography, portable home monitors, efficacy. INCLUSION CRITERIA: polysomnography, ambulatory, adults, humans. ESCLUSION CRITERIA: children.

Improving colorectal cancer screening in family medicine: an Oklahoma Physicians Resource/Research Network (OKPRN) study.

PURPOSE: The purpose of this study was to describe colorectal cancer screening (CRCS) practices across a variety of primary care clinics and identify the methods used by primary care physicians (PCPs) with higher rates of CRCS ("exemplars"). METHODS: Physician questionnaires, structured interviews, medical record abstractions, and practice observations were conducted for 48 PCPs in 25 practices within a regional practice-based research network followed by secondary in-depth interviews to further investigate the practices of PCPs in the top quartile of CRCS rates ("exemplars"). RESULTS: We abstracted 3596 medical records (mean of 75 records per PCP). Overall, exemplars had higher CRCS rates (median, 57.2% vs. 27.6%; P < .001). Patients of exemplars had higher screening rates for fecal occult blood testing (FOBT) and colonoscopy but not for flexible sigmoidoscopy or double-contrast barium enemas. Exemplars adopted few of the system-based innovations proposed by researchers to improve CRCS. Colonoscopy was promoted as the preferred CRCS method. FOBT was recommended for patients who could not afford or did not want colonoscopy. Flexible sigmoidoscopy or barium enemas were rarely recommended. Exemplars used brief CRCS promotion scripts that informally paralleled theory-driven counseling techniques. CONCLUSIONS: Experienced PCPs use brief CRCS promotion scripts including counseling techniques that improve CRCS performance. Future research should be directed toward whether these techniques can be used to create an intervention aimed at PCPs to improve CRCS.

Do older people benefit from having a confidant? An Oklahoma Physicians Resource/Research Network (OKPRN) study.

OBJECTIVE: The objective was to determine whether having a confidant was associated with improved health-related quality of life (HRQoL) or survival in older, community-dwelling individuals. METHODS: This prospective cohort study included 23 family physician members of the Oklahoma Physicians Research/Resource Network in 9 practices and 852 community-dwelling adults 65 or older participating in the Oklahoma Longitudinal Assessment of Health Outcomes of Mature Adults Studies. Longitudinal models analyzed changes in self-administered Quality of Well-Being (QWB-SA) scores over an average (S.D.) of 2.51 (1.28) years. Cox proportional hazards models assessed variables possibly associated with mortality over an average survival time (+/-S.D.) of 9.22 (3.24) years. We controlled for chronic illnesses, baseline age, gender, marital status, income, race, BMI, education and specified Medical Outcomes Study Short Form-36 (SF-36) domain scores. RESULTS: Initially, 740 participants (87%) had a confidant. Being married was strongly associated with having a confidant (91.9% vs. 77.8%, p<0.0001). A confidant was associated with better SF-36 domain scores (p<0.0001), less morbidity, higher baseline QWB-SA scores and favorable changes in QWB-SA (p<0.0001). Unadjusted risk of death (37.8% vs 46.4%, p=0.08) was not lower. Kaplan-Meier confidant status survival curves were not statistically different (p=0.16). CONCLUSIONS: Older people with a confidant demonstrated enhanced HRQoL maintenance over the short term, but not greater survival.

The law of diminishing returns in clinical medicine: how much risk reduction is enough?

The law of diminishing returns, first described by economists to explain why, beyond a certain point, additional inputs produce smaller and smaller outputs, offers insight into many situations encountered in clinical medicine. For example, when the risk of an adverse event can be reduced in several different ways, the impact of each intervention can generally be shown mathematically to be reduced by the previous ones. The diminishing value of successive interventions is further reduced by adverse consequences (eg, drug-drug, drug-disease, and drug-nutrient interactions), as well as by the total expenditures of time, energy, and resources, which increase with each additional intervention. It is therefore important to try to prioritize interventions based on patient-centered goals and the relative impact and acceptability of the interventions. We believe that this has implications for clinical practice, research, and policy.