DynaMed EBM Focus 51: Year in Review

EBM Focus - Volume 10, Issue 51

In 2015, the DynaMed Editors considered 27,017 articles and 8,737 articles were included in DynaMed Plus. Each week, from an average of 168 articles added to DynaMed Plus, editors selected articles that were considered “most likely to inform clinical practice.”

In this “Year in Review” issue, the DynaMed Editors share a recap of the 5 most important articles from 2015. We welcome your comments on how your clinical practice was affected by the information presented. Comments can be sent to DynaMedEditor@ebscohost.com.

We would like to thank our readers for their support and input throughout the year. Your feedback helps improve the DynaMed Plus EBM Focus for the global DynaMed Community.

With our very best wishes for a joyous and peaceful New Year,
The DynaMed Editors

Consumption of Peanut Products During Infancy May Reduce the Incidence of Peanut Allergy Compared to Peanut Avoidance in High Risk Children

Reference: LEAP Trial (N Engl J Med 2015 Feb 26;372(9):803) (level 2 [mid-level] evidence)

Peanut allergies in children are on the rise world-wide, with an increase in self-reported childhood peanut allergies in the United States from 0.4% in 1997 to 1.4% in 2008 (World Allergy Organ J 2013 Dec 4;6(1):21, J Allergy Clin Immunol 2010 Jun;125(6):1322). In 2000, the American Academy of Pediatrics recommended excluding peanuts from the diets of pregnant and nursing mothers of infants at high risk for developing allergies and excluding peanuts from the child’s diet until 3 years of age (Pediatrics 2000 Aug;106(2 Pt 1):346). This recommendation was removed in 2008, however, with the increasing prevalence of peanut allergies and new studies finding elimination of food allergens from diet did not prevent the development of food allergies (Pediatrics 2008 Jan;121(1):183, N Engl J Med 2003 Mar 13;348(11):977, Pediatrics 2006 Feb;117(2):401), but the questions surrounding timing of food introduction for the prevention of food allergies remain. A recent randomized trial of 640 infants aged 4-11 months at high risk for developing allergies compared peanut consumption vs. peanut avoidance until age 60 months. High risk infants were defined as those with severe eczema, egg allergy, or both.

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Thrombolysis 3-4.5 Hours After Stroke Onset May Increase Mortality Without Clear Benefit

Reference: BMJ 2015;350:h1075

Thrombolysis with alteplase (tissue-type plasminogen activator, t-PA) given up to 3 hours after the onset of acute ischemic stroke is associated with an increased likelihood of survival without disability at 90 days. Multiple systematic reviews have suggested the benefit of t-PA is found for use up to 4.5 hours after stroke onset. The data supporting t-PA for up to 4.5 hours after stroke onset has led to strong recommendations for such use in guidelines in the United States, United Kingdom, Canada, Europe, France, Japan, Australia, and South Africa. Drug licensing for t-PA after stroke is limited to the first 3 hours in the US but is extended to 4.5 hours in the UK and Australia.

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Supplemental Oxygen May Be Harmful in Normoxive Patients with ST-Elevation Myocardial Infarction

Reference - AVOID trial (Circulation 2015 May 22 early online) (level 2 [mid-level] evidence)

Supplemental oxygen therapy is commonly given as part of the initial treatment to all patients with ST-elevation myocardial infarction (STEMI), even when the oxygen saturation is normal, though studies supporting its use are limited. Current guidelines recommend administration of oxygen in patients with STEMI presenting with hypoxia, but exact definitions and recommendations vary (Circulation. 2013 Jan 29;127(4):e362-425, Eur Heart J. 2012 Oct;33(20):2569-619). A previous Cochrane review found routine oxygen therapy may not reduce mortality in patients with suspected or proven acute myocardial infarction (Cochrane Database Syst Rev 2013 Aug 21;(8):CD007160), but only 4 trials (all with wide confidence intervals) were included in this analysis. A recent randomized trial compared oxygen supplementation at 8 L/min vs. no oxygen supplementation in 441 adults with normal oxygen saturation who had chest pain for

< 12 hours and confirmed STEMI. Patients with suspected STEMI on prehospital electrocardiogram and oxygen saturation > 94% (638) were randomized by paramedics who initiated therapy before hospital admission. Paramedics also administered aspirin 300 mg orally to all patients. Only patients later confirmed to have STEMI by emergent coronary angiography were included in the analysis.

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Higher Rates of Mammography Screening Associated with Higher Rates of Breast Cancers, but not Associated with Decreased Breast Cancer Mortality

Reference: JAMA Intern Med 2015 Jul 6 early online (level 2 [mid-level] evidence)

Routine mammography for breast cancer screening is recommended beginning as early as age 40 for women with an average risk of breast cancer (CA Cancer J Clin 2012 Mar-Apr;62(2):129, USPSTF Screening for Breast Cancer 2009 Nov). As the rate of mammography increases, however, so does the potential for overdiagnosis and overtreatment. Overdiagnosis occurs if screening leads to diagnosis of cancers that would never have affected the patients’ health or longevity. Mammography has been associated with an increase in the detection of early stage breast cancer, but only a small reduction in the incidence of late-stage breast cancer (N Engl J Med 2012 Nov 22;367(21):1998). Furthermore, results on the benefit of mammography for the prevention of breast cancer-associated mortality have been mixed and the extent of overdiagnosis remains unclear (Cochrane Database Syst Rev 2013 Jun 4;(6):CD001877, BMJ 2014 Feb 11;348:g366). A recent retrospective cohort study evaluated 16,120,349 women ≥ 40 years old having screening mammography in the year 2000 in one of 547 United States counties reporting to Surveillance, Epidemiology, and End Results (SEER) database.

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Adjunctive Corticosteroid Therapy for Community-Acquired Pneumonia

Reference - Ann Intern Med 2015 Oct 6;163(7):519 (level 2 [mid-level] evidence)

Community-acquired pneumonia is a major cause of morbidity and mortality worldwide. In the United States, the annual incidence of community-acquired pneumonia requiring hospitalization is 24.8 cases per 10,000 adults. This incidence sharply increases for adults ≥ 65 years old (N Engl J Med 2015 Jul 30;373(5):415). Current guidelines recommend empiric antibiotic therapy as the mainstay of treatment for community-acquired pneumonia (Clin Infect Dis 2007 Mar 1;44 Suppl 2:S27). However, a growing body of evidence, including two recent randomized trials, has suggested adjunctive corticosteroids may provide additional benefit in some populations (JAMA 2015 Feb 17;313(7):677, Lancet 2015 Apr 18;385(9977):1511, EBM focus 2015 Apr:10(16)). To further examine this potential benefit, a recent systematic review and meta-analysis compared adjunctive corticosteroid therapy vs. placebo or no treatment in 2,005 adults with community-acquired pneumonia in 13 randomized trials. Trials including patients with ventilator-associated pneumonia, aspiration pneumonia, or Pneumocystis jiroveci pneumonia and trials limited to patients with chronic obstructive pulmonary disease were excluded.

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