"The education of the doctor that goes on after he has his degree is, after all, the most important part of his education."
- John Shaw Billings.

Contents

- POEMS

- A medical representative’s visit

- Any Questions

POEMs: -
The acronym POEMs stands for Patient-Oriented Evidence that Matters, and refers to summaries of valid research that is relevant to physicians and their patients. POEMs are selected from research published in more than 100 clinical journals. Each month, a team of family physicians and educators reviews these journals and identifies research results that are important and can be applied to day-to-day practice. POEMs have to meet three criteria: they address a question that primary care physicians face in day-to-day practice; they measure outcomes important to physicians and patients, including symptoms, morbidity, quality of life, and mortality; and they have the potential to change the way physicians practice. Studies that do not meet these criteria cannot be a POEM.

Brief texts of select POEMs are stated below. For further details, please follow individual references: -

Clinical question What diagnostic strategy best identifies patients with nonspecific abdominal pain who will require urgent intervention?

Bottom line A structured clinical evaluation combined with laboratory analysis, x-ray, and non contrasted helical computed tomography (CT) best identifies patients with nonspecific abdominal pain who will need urgent intervention. (Level of evidence = 3b)

Ref - Gerhardt RT, Nelson BK, Keenan S, et al. Derivation of a clinical guideline for the assessment of nonspecific abdominal pain: the Guideline for Abdominal Pain in the ED Setting (GAPEDS) Phase 1 Study. Am J Emerg Med. 2005;23:709-717.

Clinical question Does aspirin prevent cardiovascular disease in women?

Bottom line Aspirin reduces the risk of stroke and transient ischemic attack in women but does not reduce the risk of MI or cardiovascular (CV) death. The reduction in strokes over 10 years (number needed to treat = 444) must be balanced against an increase in serious GI bleeds (number needed to treat to harm = 553). No change was seen in this large, long study regarding all-cause mortality. (Level of evidence = 1b*)

Ref;- Ridker PM, Cook NR, Lee IM, et al. A randomized trial of low-dose aspirin in the primary prevention of cardiovascular disease in women. N Engl J Med. 2005;352:1293-1304.

Clinical question How accurate is a trial of a proton pump inhibitor (PPI) for the diagnosis of gastroesophageal reflux disease (GERD), and how effective are PPIs for the treatment of noncardiac chest pain?

Bottom line The use of a PPI is helpful in the diagnosis of GERD and is an effective treatment for patients with noncardiac chest pain. Because some smaller studies with negative results may not have been published, the estimate of the degree of benefit of PPIs in this study may be on the high side. (Level of evidence = 1a*)

Ref - Cremonini F, Wise J, Moayyedi P, Talley N. Diagnostic and therapeutic use of proton pump inhibitors in non-cardiac chest pain. Am J Gastroenterol. 205;100:1226-32.

Clinical question In patients with type 2 diabetes who are NOT using insulin, does home glucose monitoring improve care?

Bottom line Intensive monitoring of blood glucose in patients with type 2 diabetes not using insulin results in a small decrease in hemoglobin A1c (HbA1c) levels but does not change fasting blood glucose levels. Urine glucose monitoring works just as well. More casual monitoring of blood glucose, such as once a day, has not been studied. There is a strong possibility that the weak study design was largely responsible for the difference seen in the study. Blood glucose monitoring is expensive: At the intense level of monitoring used in some of these studies (6 times a day), the cost of the monitoring strips alone can be $2000 US per year. (Level of evidence = 1a*)

Ref - Welschen LM, Bloemendal E, Nijpels G, et al. Self-monitoring of blood glucose in patients with type 2 diabetes who are not using insulin. Diabetes Care. 2005;28:1510-1517.

• Level A (randomized controlled trial/ meta-analysis): High-quality randomized controlled trial (RCT) that considers all important outcomes. High-quality meta-analysis (quantitative systematic review) using comprehensive search strategies.
• Level B (other evidence): A well-designed, nonrandomized clinical trial. A nonquantitative systematic review with appropriate search strategies and well-substantiated conclusions. Includes lower quality RCTs, clinical cohort studies, and case-controlled studies with nonbiased selection of study participants and consistent findings. Other evidence, such as high-quality, historical, uncontrolled studies, or well-designed epidemiologic studies with compelling findings, is also included.
•  Level C (consensus/expert opinion): Consensus viewpoint or expert opinion.

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A Medical representative’s visit –

A common office scenario is described, followed by questions. Each question contains five responses, for EACH response (A to E), answer true (T) or False (F): -

A medical representative gives you an article in which 50 patients were given an antihypertensive drug and another 50 patients were given placebo. The drug showed impressive reduction in blood pressure with no side effects.

A – You should consider switching your poorly controlled hypertensive pts to the         new drug
B – The study suggests that this drug may have fewer side effects than other         commonly used drugs
C – If the drug has been licensed by the Food & Drug Administration (FDA)in the        US, there is probably good evidence that the drug is better than the existing        drugs
D – It would be expected that in the placebo treated group in this study there        would not be any blood pressure reduction
E – The number of patients who defaulted follow up in each group is relevant as        this may bias this study

Answers –     
  A : F                B : F                C : F                D : F                E : T

Explanation – Most pts. with chronic diseases are poorly controlled not due to wrong drug or inadequate dosage, but due to poor compliance, especially with non- pharmacological (life style) advice. Switching such difficult pts. to a new drug is unlikely to improve BP control. Further, because the drug has been compared with a placebo rather than an existing medication, whether it is better than current medication cannot be established. The group treated with placebo should also have a reduction in BP. This is the placebo effect. The US FDA usually requires evidence of effectiveness from randomized-controlled trials (level A evidence) before licensing a drug. This does not mean it is better than existing drugs. The default rate is important as an important cause of default by pts. is the side effects they have experienced, which may not be accounted in such drug study. A high default rate, especially if it is unequal in the two groups, will bias the study. Side effects of drugs only become known through post-marketing surveillance and trials of this sort do not give a correct picture of the side effects of drugs.

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ANY QUESTIONS

Whether significant reductions in LDL cholesterol and serum triglyceride levels will lead to significant reductions in coronary mortality when starting lipid values are "normal" is a multifaceted question without a precise answer.

An important issue relates to the definition of "normal" values. The AVERT Trial (i.e. Atorvastatin Verses Revascularization Treatment -1999) showed that higher-than-usual doses of statin therapy (up to 80 mg of atorvastatin was used) achieved marked reduction of LDL levels, well below the target value of 100 mg/dL suggested for patients with diabetes or CAD. The participants with levels below target values demonstrated better clinical results, such as fewer hospitalizations and less need for a revascularization procedure, than a comparison group of patients treated with angioplasty. This degree of beneficial cardiovascular protection would probably not have been achieved if dosing increase of the statin drug had been stopped once LDL levels achieved a "normal" level.

The effect of statin use on primary prevention of coronary disease in subjects with normal baseline lipid values is even harder to define, especially when the cost-efficacy of long-term therapy in otherwise low-risk subjects is factored into the equation. What is known is that elevated LDL levels identify fewer than 50% of those who will ultimately die from CAD. Other factors in CAD that are often difficult to quantify, such as lipoprotein-a, C-reactive protein, fibrinogen, plasma viscosity, and heredity, may alter the effect that a "high normal" lipid value may have in the atherogenic process.

Finally, other mechanisms besides the lipid lowering are clearly operative in the statin cardio protective effect. Despite less than a 2% to 5% increase in coronary artery lumen diameter being achieved in most angiographic lipid-treatment and follow-up studies, coronary mortality is disproportionately improved. Other benefits seem to accrue from related mechanisms, such as improved endothelial function, plaque stabilization, reduction in the inflammatory response, and modification of thrombogenesis. These changes probably begin very soon after starting statin therapy.

Based on the evidence available at this time, the answer to the question raised is, therefore, yes. Evidence suggests that statin therapy may provide a beneficial cardio protective effect even in patients with seemingly "normal" lipid levels. Exciting implications of this suggestive evidence include the potential role of statin therapy in the treatment of acute coronary syndromes as an adjunct treatment to rapidly improve endothelial function/plaque stability. In addition, a rationale now exists for considering statin therapy as a secondary prevention measure for patients with significant CAD who have serum cholesterol levels that fall within the "normal" range.

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References –

• Henry D et al. Comparing treatments – BMJ 1995; 310:1279
• www.medscape.com
• J.of Am. Assoc. Of   Phy Assist.- archives.

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