POEMs

				Using the search form

If you prefer to view this article in PDF form, click here.

Routine funduscopy not useful in hypertensives

Clinical question Is routine funduscopy useful in identifying retinopathy in hypertensive patients?

Bottom line It is uncommon to see retinal changes by funduscopic examination in patients with hypertension, although when retinal changes occur, they are almost always associated with hypertension. Though no studies have been performed to check the reliability of a funduscopic examination, there was only moderate agreement between two clinicians evaluating photographs of the retina of hypertensive patients for early changes. (Level of evidence = 4)

Van den Born BJ, Hulsman CA, Hoekstra JB, et al. Value of routine funduscopy in patients with hypertension: systematic review. BMJ. 2005;331:73-6.

Synopsis The researchers conducting this systematic review searched 3 databases to find studies evaluating the assessment of the retina for microvascular changes. The searches were done independently by two researchers and compared. They included studies assessing the agreement between at least two clinicians assessing photographs of the retina of hypertensive patients; in five studies agreement between evaluators was fair or moderate for arteriolar narrowing (kappa=0.3-0.4) and arteriovenous nicking (kappa=0.4-0.6) and excellent for hemorrhages and exudates (kappa=0.76-0.9). In four large population-based studies, retinopathy occurred in relatively few patients with hypertension, giving it a low sensitivity (3%-21%). However, when it occurred, it was almost always in patients with hypertension (88%-98%), giving it a high specificity.

Low-dose aspirin doesn’t lower women’s cancer risk (WHS)

Clinical question Is low-dose aspirin effective in reducing the risk of cancer among healthy women?

Bottom line Low-dose aspirin does not reduce the risk of lung, breast, colorectal, or other site cancer in healthy women 45 years and older. There may be a protective effect reducing lung cancer mortality, but overall mortality is not reduced. (Level of evidence = 1b)

Cook NR, Lee IM, Gaziano JM, et al. Low-dose aspirin in the primary prevention of cancer. The Women's Health Study: A randomized controlled trial. JAMA. 2005;294:47-55.

Synopsis Evidence from observational trials suggest that aspirin may be effective in preventing cancer. In the Women's Health Study, the investigators randomized (concealed allocation assignment) 39,876 healthy women, 45 years and older, to receive either aspirin, 100 mg, every other day or placebo. Individuals blinded to treatment assignment assessed outcomes. Follow-up occurred for an average of 10.1 years for more than 97% of the subjects. Using intention-to-treat analysis, aspirin did not significantly reduce the incidence of any cancer, including breast, colorectal, and lung. There was no reduction in cancer mortality either overall or by site, except for lung cancer mortality (number needed to treat for 10 years=800). All-cause mortality was also not reduced by aspirin.

PPIs effective for diagnosis, treatment in noncardiac chest pain

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)

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.

Synopsis This was actually two studies in one, and it did a good job of clarifying the accuracy and extent of benefit of PPIs in the diagnosis and treatment of noncardiac chest pain. The authors performed an adequate search of the literature, including not only MEDLINE but also Embase, the Cochrane Controlled Trials Register, and a hand search of meeting abstracts. For the meta-analysis of the diagnosis of GERD using PPIs, acid reflux was diagnosed using 24-hour pH monitoring as the reference standard test and heart disease was excluded using appropriate tests (8 studies with 321 patients). Studies were not heterogeneous, and the pooled sensitivities and specificities for the outcome of “greater than 50% response” were 83% and 75%. Given the overall prevalence of esophagitis using the reference standard test of 22%, this corresponds to positive and negative predictive values of 48% and 94%, respectively. The sensitivity was much lower (46%) when the outcome used was “any response.”

For the meta-analysis of treatment of noncardiac chest pain, only randomized trials that blinded patients to treatment assignment, used intention-to-treat analysis, and had a placebo control group were included (7 studies with 232 patients). Using the outcome of “greater than 50% response” as the definition of success, the number needed to treat for PPIs in patients with noncardiac chest pain was 3 (pooled risk ratio=0.54; 95% CI, 0.41-0.71). There was no significant benefit if the stricter criterion of “complete resolution” of chest pain was used. There was evidence of publication bias, with an absence of small studies that showed less benefit.

Lower risk of type 2 diabetes in coffee drinkers

Clinical question Does habitual coffee drinking reduce the risk of type 2 diabetes?

Bottom line Habitual coffee drinking is associated with a reduced risk for type 2 diabetes. The greatest risk reduction occurred among individuals consuming 6 or more cups of filtered coffee daily. Decaffeinated and caffeinated brews are equally effective. (Level of evidence = 2a)

van Dam RM, Hu FB. Coffee consumption and risk of type 2 diabetes. A systematic review. JAMA. 2005;294:97-104.

Synopsis Coffee contains numerous biochemical substances that affect glucose metabolism. These investigators systematically reviewed the evidence on the relation between coffee intake and risk of type 2 diabetes. Their search strategy included MEDLINE and reference lists of retrieved articles in English. Two investigators independently identified a total of fifteen studies, including nine cohort (prospective) studies and seven cross-sectional (descriptive) studies. Compared with the lowest coffee consumption category (0 to 2 cups per day), the highest (6 cups or more per day) and the second highest (4 to 6 cups per day) consumption categories showed a significantly reduced risk of type 2 diabetes (number needed to treat [NNT]=36; 95% CI, 27-57; and NNT=45; CI, 33-74, respectively). These associations did not differ after controlling for numerous confounding variables, including sex, age, obesity, smoking status, alcohol consumption, and physical activity. The risk was lower with filtered coffee than pot-boiled coffee, but both decaffeinated and caffeinated were equally protective. Adding a small amount of sugar or milk did not affect risk reduction. The authors formally assessed for both publication bias and heterogeneity and found no evidence of either.

Levels of evidence are explained at www.infopoems.com/levels.html.