Evidence-Based Approaches to Common Primary Care Dilemmas, Part I, An Issue of Primary Care Clinics in Office Practice (The Clinics: Internal Medicine) (Pt. 1)

Cover......Page 1
Preface......Page 2
An Introduction to Evidence-Based Medicine......Page 4
Definition of evidence-based medicine......Page 6
Evidence-based medicine focuses on patient outcomes......Page 7
Step 1. Develop a specific answerable question from a clinical problem......Page 8
Step 2. Search the best evidence that answers that question......Page 9
Step 3. Critically assess that evidence for its relevance, validity, and usefulness to the patient and practice......Page 10
Step 5. Evaluate the performance of that practice and revise as new evidence becomes available......Page 19
Summary......Page 20
References......Page 21
Evolving Medical Knowledge: Moving Toward Efficiently Answering Questions and Keeping Current......Page 23
References......Page 27
Is the article from a peer-reviewed journal?......Page 30
Step one: conduct an initial validity and relevance screen......Page 32
Is the study sponsored by an organization that may influence the study design or results?......Page 33
Will this information, if true, require me to change my current practice?......Page 34
Step three: evaluate the validity of the article based on its intent......Page 35
Is the study a randomized controlled trial?......Page 36
Are the subjects in the study similar to mine?......Page 37
Are all participants who entered the trial properly accounted for at its conclusion?......Page 38
Are the results clinically as well as statistically significant?......Page 40
Were there other factors that might have affected the outcome?......Page 43
Suggested readings on critical reading skills......Page 44
Step one in critically assessing an original research article......Page 48
Determining validity of an article about therapy......Page 49
Determining validity of an article about causation......Page 50
Determining validity of an article about prognosis......Page 51
References......Page 52
Smoking cessation......Page 54
Estimating probability of significant coronary artery disease in the asymptomatic patient......Page 55
Cardiac stress imaging......Page 57
Invasive testing......Page 58
Screening diabetic patients......Page 59
Preoperative evaluation......Page 60
Antiplatelet therapy and anticoagulation......Page 61
Lipid-lowering therapy......Page 62
Angiotensin-converting enzyme inhibitor therapy......Page 63
Revascularization......Page 64
Risk factor modification......Page 65
Counseling......Page 66
Alternative therapies......Page 67
Monitoring patients with known coronary artery disease......Page 68
Use of cardiac testing during follow-up......Page 70
References......Page 71
Heart failure......Page 77
Prognosis......Page 78
The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure......Page 79
Evaluation......Page 80
Treatment: lifestyle modification......Page 81
Essential hypertension......Page 82
Patients who have concomitant diagnoses......Page 83
Coronary artery disease......Page 84
Diabetes......Page 85
Shape Up America (http://www.shapeup.org/10000steps.html)......Page 86
References......Page 87
All-cause and cardiovascular mortality......Page 92
Bottom line......Page 93
Evidence summary......Page 94
Clinical commentary......Page 95
Evidence summary......Page 96
Bottom line......Page 98
Evidence summary......Page 99
Evidence summary......Page 100
Diabetes mellitus......Page 101
Evidence summary......Page 102
Bottom line......Page 103
Evidence summary......Page 104
Evidence summary......Page 105
Evidence summary......Page 106
Summary......Page 107
References......Page 108
An Evidence-Based Approach to the Management of Depression......Page 111
Should physicians screen for depression and which screening tool should be used?......Page 112
Are there any meaningful differences between newer and older antidepressants?......Page 113
What drugs should primary care physicians prescribe first-line for depression?......Page 114
If patients are not responding to treatment, what should be done next?......Page 115
How long should patients who have depression be treated with antidepressants?......Page 116
Which antidepressants are safe in pregnancy?......Page 117
Should antidepressants be used in patients who have experienced a myocardial infarction or stroke?......Page 118
Does counseling provide a measurable therapeutic effect in depressed patients?......Page 119
Should health care providers recommend an exercise program for their patients who suffer from depression?......Page 120
What is evidence behind hormonal supplements?......Page 121
Is there any proven benefit of light therapy in the treatment of depression?......Page 122
What about collaborative therapy and disease management programs?......Page 123
Are there any other treatment modalities that are supported by evidence?......Page 124
References......Page 125
Osteoporosis......Page 130
Vitamin D......Page 131
Risk factors......Page 132
Screening frequency......Page 134
Bisphosphonates......Page 135
Raloxifene......Page 136
Parathyroid hormone......Page 137
References......Page 138
Women’s Health Initiative......Page 139
Other studies and the type of breast cancer......Page 141
North American Menopause Society......Page 142
Nonoral estrogens......Page 143
Botanicals......Page 145
‘‘Off-label’’ therapy......Page 146
References......Page 147