DynaMed EBM Focus: 2016 Year in Review Part II

EBM Focus - Volume 11, Issue 52

Read the full EBM Focus and earn CME credit.

In 2016, the DynaMed Editors considered 39,345 articles and 9,013 articles were included in DynaMed Plus. Each week, from an average of 180 articles added to DynaMed Plus, editors selected articles that were considered “most likely to inform clinical practice.”

As a “Year in Review,” the EBM Focus presents the 10 most important articles from 2016. The top 5 were presented in the previous issue and the next 5 are shown here. We welcome your comments on how your clinical practice was affected by the information presented. Comments can be sent to dynameder@ebsco.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

Antibiotics in Women with Uncomplicated Urinary Tract Infections May Not Be Necessary
Reference - BMJ 2015 Dec 23;351:h6544 (level 1 [likely reliable] evidence)

Increasing rates of antibiotic resistance have strengthened the need for judicious antibiotic use and antimicrobial stewardship. Current recommendations support immediate antibiotic therapy for uncomplicated urinary tract infections (UTIs) (Clin Infect Dis 2011 Mar 1;52(5):e103, EAU 2015 Mar PDF), even though some data suggests that many uncomplicated UTIs are self-limited (Curr Infect Dis Rep 2013 Apr;15(2):124). To assess the potential to treat UTI symptoms without antibiotics, a recent randomized trial compared ibuprofen 400 mg 3 times daily vs. single dose fosfomycin 3 g in 494 women aged 18-65 years with symptoms of uncomplicated UTI. UTI symptoms considered for trial inclusion were dysuria or frequency/urgency of micturition, with or without lower abdominal pain. Women were excluded for symptoms of upper urinary tract infection including fever or loin tenderness. Both groups received placebo pills for the corresponding active treatment given to the other group to maintain blinding. Urine cultures and dipstick tests were performed, but the results did not inform eligibility. All women were advised to consult their general practitioner if symptoms persisted or worsened, at which point antibiotic treatment was prescribed at the discretion of the practitioner based on the initial urine culture results.

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Addition of Spinal Fusion to Decompression Does Not Benefit Patients with Lumbar Spinal Stenosis
Reference - Swedish Spinal Stenosis Study (SSSS) (N Engl J Med 2016 Apr 14;374(15):1413) (level 1 [likely reliable] evidence)

The North American Spine Society (NASS) recommends decompressive surgery to improve outcomes in patients with moderate-to-severe lumbar spinal stenosis (Spine J 2013 Jul;13(7):734). Lumbar fusion is not suggested for patients with leg predominant symptoms without instability (Spine J 2013 Jul;13(7):734), but is currently recommended in patients with single-level degenerative lumbar spondylolisthesis and > 20% slippage (NASS May 2013 PDF). In practice, the use of simple fusion is common in either case. In the United States, approximately 25% of patients with lumbar spinal stenosis alone and 80% of patients with lumbar spinal stenosis plus coexisting spondylolisthesis or spondylolysis have lumbar fusion (Spine (Phila Pa 1976) 2013 May 15;38(11):916). However, the evidence supporting spinal fusion during decompression surgery is limited. To evaluate if spinal fusion is associated with increased long-term benefits, the SSSS trial compared decompression plus fusion surgery vs. decompression surgery alone in 247 patients aged 50-80 years with lumbar spinal stenosis.

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Delaying Supplemental Parenteral Nutrition Benefits Critically Ill Children
Reference – N Engl J Med 2016 Mar 24;374(12):1111 (level 1 [likely reliable] evidence)

Evidence evaluating nutritional support for critically ill children admitted to a PICU is sparse and studies performed in adult populations may not adequately translate to growing children with different nutritional needs. Nevertheless, current guidelines recommend early nutritional evaluation and the initiation of aggressive feeding protocols to prevent or combat malnutrition in critically ill children (JPEN J Parenter Enteral Nutr 2009 May-Jun;33(3):260). Enteral nutrition provided by a nasogastric tube is the preferred method for supplying nutritional support, but enteral nutrition is frequently interrupted or not tolerated (Crit Care Med 2012 Jul;40(7):2204, Pediatr Crit Care Med 2016 Jan;17(1):10). Supplemental parenteral nutrition is often administered to adequately meet nutritional goals, but may increase the risk of complications such as infection (JPEN J Parenter Enteral Nutr 2016 Jan 7 early online). To further evaluate this issue, 1,440 critically ill children (median age 18 months) admitted to the PICU with medium-to-high risk of malnutrition were randomized to supplemental parental nutrition initiated within 24 hours of PICU admission (early) vs. on PICU day 8 (late).

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Oxygen therapy with SpO2 94%-98% may reduce mortality compared to therapy with SpO2 97%-100% in patients admitted to intensive care unit
Reference - JAMA 2016 Oct 18;316(15):1583 (level 2 [mid-level] evidence)

For critically ill patients receiving oxygen therapy, there is limited data to guide the oxygenation targets and studies suggest that liberal use of oxygen therapy resulting in hyperoxia is common (Respir Care 2012 Nov;57(11):1887, J Crit Care 2013 Oct;28(5):647). Two previous randomized trials investigating mortality following lower versus higher oxygenation strategies have been performed and no benefit has been found from higher oxygenation targets with possible harm reported in patients having surgery for cancer (JAMA 2009 Oct 14;302(14):1543, Anesth Analg 2012 Oct;115(4):849, Am J Respir Crit Care Med 2016 Jan 1;193(1):43). To further investigate optimal oxygenation targets, a recent trial randomized 480 adults (median age 64 years) admitted to an ICU with an expected stay > 72 hours to lower oxygen therapy with SpO2 target of 94%-98% versus higher therapy with SpO2 target of 97%-100%.

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Half-strength Apple Juice May Reduce Need for IV Rehydration Compared to Electrolyte Maintenance Solution in Children with Mild Gastroenteritis and at Most Mild Dehydration
Reference - JAMA 2016 May 10;315(18):1966 (level 2 [mid-level] evidence)

Oral rehydration solution is the initial treatment for most children with gastroenteritis and acute diarrhea, as it serves to prevent and treat associated dehydration (J Pediatr Gastroenterol Nutr 2014 Jul;59(1):132). Electrolyte maintenance solution can be costly and the taste is unacceptable to many children (Pediatrics 1994 May;93(5):708). As a result, some children (even those with mild symptoms) become increasingly dehydrated, and as a result are taken to the emergency department to receive intravenous rehydration. A recent randomized noninferiority trial investigated whether the need for subsequent intravenous rehydration could be reduced by giving children with acute gastroenteritis half-diluted apple juice (or similar preferred fluid) instead of electrolyte maintenance solution.

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