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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 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 • 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.
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.
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
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
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?
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
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
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.
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)
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 .
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).