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4 BEAR’s

4 BEAR’s. By John Smith, R1. BEAR #1:Case & Question. 55 y.o. ♀ with vaginal dryness Does Vaginal Estrogen ↑ the risk of endometrial hyperplasia & cancer (and should progesterone be added)? Search > Pubmed Abstract Cochrane College Guideline (SOCG). BEAR #1: Reference 1 & 2.

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4 BEAR’s

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  1. 4 BEAR’s By John Smith, R1

  2. BEAR #1:Case & Question • 55 y.o. ♀ with vaginal dryness • Does Vaginal Estrogen ↑ the risk of endometrial hyperplasia & cancer (and should progesterone be added)? • Search > • Pubmed • Abstract • Cochrane • College Guideline (SOCG)

  3. BEAR #1: Reference 1 & 2 • Abbreviated Citation: J Womens Health 2002;11(10):857-77 (Abstract Only) • Strengths: Meta-analysis of lots of trials (22) • Weaknesses: Limited safety data & trials short • Take-Home Message: Limited evidence for long-term safety (Tab may have best safety evidence). • Abbreviated Citation: Cochrane Database Syst Rev 2003; (4): CD001500 • Strengths: 16 Trials (14 safety), 2129 pts. Good reporting (e.g. AC & ITT) • Weaknesses: Lots of heterogeneity, Trials Short (15 were ≤6months) • Take-Home Message: Hyperplasia can occur but not consistent. Ring/Tab seems best.

  4. BEAR #1: Reference 3 + Bottom-line • Abbreviated Citation: J Obstet Gynaecol Can 2004; 26(5): 503-8 • Strengths: Clear recommendation for clinic practice • Weaknesses: Would be better with more description of the studies • Take-Home Message: Endometrial surveillance or progesterone not needed • Bottom-Line: May be hyperplasia but Uterine Ca still ?. Okay to Give without surveillance or progesterone (but would like advise patients). Safety perhaps Tab or Ring > Cream.

  5. BEAR #2:Case & Question • 60 y.o. ♀ non-smoker, hypertensive, mild hyperlipidemia asking about Aspirin • What are the benefits & risks of ASA therapy for women in primary CAD prevention? • Search > • ACP Journal Club • Clinical Evidence (Summary Web site) • Pubmed: Abstract

  6. BEAR #2: Reference 1 & 2 • Abbreviated Citation: ACP Journal Club. 2002 Jul-Aug; 137:6. • Strengths: NNT all CAD= 150, NNH bleed= 300, stratify risk group • Weaknesses: Do not separate Females & males • Take-Home Message: Men/women Risk ≥3% benefits>harm but Risk≤1% benefits<harm • Abbreviated Citation: Clinical Evidence (primary prevention) 2002(Nov) • Strengths: NNT =10/10,000, NNH cranial & other bleed =1 & 7 / 10,000 • Weaknesses: Do not separate Females & males • Take-Home Message: As above + unclear benefit/risk between 1-3% risks

  7. BEAR #2: Reference 3 + Bottom-line • Abbreviated Citation: NEJM. 2005 31;352(13):1293-304 • Strengths: High power RCT, only Female Prime Prevent. CAD Non-sign,NNT Stroke=455, NNH serious bleed =556, NNH ulcer =153 • Weaknesses: Recruitment & Run-in. AC ? • Take-Home Message: Limited benefits (only stroke sign), harms freq • Bottom-Line: Benefits of ASA in 1° prevention of CAD in Women are low. Perhaps only stroke risk significantly reduced (NNT=455) but harms sign (NNH serious bleed=556, ulcer=153, etc). When 5year CAD risk is less than 3%, harm may exceed benefit?

  8. BEAR #3:Case & Question • 40 y.o. male with 1 sister & mother with early breast Ca, should any screening be done. • In males with a strong family history for breast cancer is any particular referral or testing recommended ? • Search > • Pubmed: • Abstract (multiple, none helpful) • Article • PBSGL module

  9. BEAR #3: Reference 1 & 2 • Abbreviated Citation: Genetic screening (PBSGL Mod: 2002 May; 10(6) • Strengths: Good background, clear recommendations for referral • Weaknesses:No clear answer about testing males for breast Ca • Take-Home Message: Males of high family risk - genetics referral & Prostate screening • Abbreviated Citation: Radiology2004;230:553-555 • Strengths: Gives evidence - Breast Ca screening in men with genetic risk • Weaknesses: Although this is the best evidence it is a case report only • Take-Home Message: In males w BRCA 2, screening w mammogram maybe reasonable

  10. BEAR #3: Bottom-line • Bottom-Line: Our patient needs referral to genetic counseling, increased surveillance for skin and prostate cancer. As well, if he is BRCA 2 positive (or with recommendations from genetics), he may require mammography.

  11. BEAR #4:Case & Question • 45 y.o. ♀ with anxiety & chest pain, ER tests Normal but ER doc suggests Stress testing • Is exercise stress testing useful to rule-in or out coronary artery disease in low risk women (what are the likelihood ratios)? • Search > • ACP Journal Club • Pubmed • Abstract • Article (same one from ACP)

  12. BEAR #4: Reference 1 & 2 • Abbreviated Citation: ACP Journal Club. 1999 July-Aug;131:21. • Strengths: Good numbers (19 trials, 3700 pts), best recent (filtered) article • Weaknesses: LR’s poor, commentary limited help, need whole article • Take-Home Message: +ve LR 2.3 (1.8-2.7), -ve LR 0.55 (0.47-0.62), • Abbreviated Citation: Am J Cardiol 1999; 83: 660-666 • Strengths: Good search, looked at study quality, provided all study LR’s • Weaknesses: Not enough heterogeneity info (but 2ndary analysis to↓ bias) • Take-Home Message: Best +LR=4 and Best –LR=0.18, but overall average as above .

  13. BEAR #4: Bottom-line • Bottom-Line: High false +ve’s & -ve’s overwhelm exercise stress test utility (and may deceive). Poor LR’s will effect the pre-test probability of CAD minimally. Female pts requesting (or referred) exercise stress testing should be made aware of these limits. (That said, in many cases the alternatives are limited).

  14. Any Questions

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