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Archived Clinical Practice Assessments

The following is a list of archived Clinical Practice Assessments.

 
Bariatric Surgery
Bisphosponates and ONJ
CAC Score
Carotid Intima
Chest CT and Lung Cancer
Clopidogrel and PPI
Colorectal Cancer (CRC) Screening
COX-2
Delayed vs. Immediate Treatment for TIA
DM Diet
Does CPM after Total Knee Arthroplasty Improve Outcomes?
DVT - Once Daily Low Molecular Weight Heparin
Early Prostate Cancer
Epidural Steroid Injections
Floppy Iris Syndrome
GRF Equation Alternatives
Headache and Imaging
Hydroquinone
iFOB Test
Intensive Glucose Control
Intensive Statin Rx
Lab Testing During Complete Physicals
Why Lotrisone Is Seldom the Best Choice
Methotrexate
MRI and Hardware Safety
MRI Imaging and Low Back Pain
Mumps Algorithm
 
NMR Lipoprofile
NSAID GI Toxicity
Perioperative Statin Use
Pertussis
PETs for OME
Primary Prevention of Heart Disease
Post CABG/PCI Cardiac Testing
PPI Use and Hip Fracture
Preoperative Laboratory Testing
Procalcitonin Testing for Acute Respiratory Illness
PT and Low Back Pain
RAS and Stenting
Robotic Surgery
RST - A Negative Rapid Strep Test (RST) in Adults Doesn't Require A Routine Confirmatory Throat Culture
Simvastatin - Use of Generic Simvastatin will Result in Higher Value of Care for Most Patients Requiring Statin Therapy
Spirometry (Asthma)
SSRI Treatment for Major Depression
Tamoxifen
Target LDL in Patients with Ischemic Vascular Disease
Thyroid Screen for DM and Depression
Treating Barrett’s with Radiofrequency Ablation
Treating Urinary Incontinence with PTNS
Virtual Colonoscopy
VLCD and Weight Loss
VTE Prophylaxis After Knee or Hip Surgery

Bariatric Surgery

Bariatric Surgery

Clinical Question
In patients with obesity, do those who undergo a bariatric surgery procedure, compared to those managed medically, have better outcomes?

Bottom Line

Surgery appears to be a clinically effective and cost-effective intervention for moderately to severely obese people compared to non-surgical interventions. Certain procedures produce greater weight loss, but data are limited. The evidence on safety is even less clear. Due to limited evidence and poor quality of the trials, caution is required when interpreting comparative safety and effectiveness.

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Bisphosphonates and ONJ

Bisphosphonates and ONJ

Clinical Question
Are patients on bisphosphonate therapy at risk for developing osteonecrosis of the jaw (ONJ)?

Bottom Line
Osteonecrosis of the jaw has been described in patients on bisphosphonate therapy. All reports have been either case reports or small case series. The nature of the association has not been definitively established.

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Carotid Intima

Carotid Intima

Clinical Question
In patients at risk for coronary atherosclerosis, does the use of carotid intima media thickness (IMT) measurement lead to better outcomes?

Bottom Line
The clinical utility of Carotid Intima Media Thickness (IMT) measurement will remain unclear until prospective clinical trials are performed using patient oriented outcomes.

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Chest CT and Lung Cancer

Chest CT and Lung Cancer PDF

Clinical Question
In patients at increased risk for lung cancer, does screening with routine chest CT result in improved survival or quality of life compared to patients who are diagnosed on the basis of symptoms?

Bottom Line

Although spiral CT can detect early lung cancer, the evidence remains insufficient to demonstrate that chest CT screening for patients at increased risk for lung cancer decreases mortality or improves quality of life.

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Clopidogrel and PPI

Clopidogrel and PPI

Clinical Question
Does the combination of omeprazole (Prilosec) and clopidogrel (Plavix) result in increased cardiovascular events compared with clopidogrel alone?

Bottom Line
Some observational studies suggest an increase in cardiovascular events in patients on the combination (1, 2, 3) but others do not (4, 5).  The only randomized, placebo-controlled trial (6) did not demonstrate reduced clopidogrel efficacy. The decision to prescribe this combination should be made following a thoughtful discussion between prescriber and patient weighing the risks, benefits and alternatives.  This discussion should be well-documented in the chart.

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Colorectal Cancer (CRC) Screening

CRC Screening

Clinical Question
When screening average-risk patients over 50 years of age for colorectal cancer (CRC), is colonoscopy alone, or yearly fecal occult blood test (FOBT) plus either sigmoidoscopy or barium enema (BE) better than yearly FOBT alone?

Bottom Line

Screening for CRC in average-risk individuals aged 50 and older has received an “A” recommendation from the USPSTF. However, current evidence is insufficient to determine which screening modality or combination is superior. Strategies include: (1) annual FOBT alone; (2) annual FOBT and either sigmoidoscopy or barium enema (BE) every 5 years; or (3) colonoscopy alone every 10 years.

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Coronary Artery Calcium (CAC) Score

CAC Score

Clinical Question
Does the use of the coronary artery calcium score (CACS) to screen asymptomatic individuals for coronary heart disease (CHD) lead to more clinical benefit than harm?

Bottom Line
There have been no large-scale prospective trials demonstrating more benefit than harm when the CACS is used to systematically screen asymptomatic individuals.

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COX-2

COX-2
Patient Education: NSAIDs and COX-2 Inhibitors

Clinical Question

In patients requiring anti-inflammatory therapy, should COX-2 inhibitors be used?

Bottom Line

The current, available evidence does not clearly demonstrate a safe dose or duration of dosing for coxibs free of excess cardiotoxicity.

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Delayed vs. Immediate Treatment for TIA

Delayed vs. Immediate Treatment for TIA

Clinical Question
For patients with acute TIA symptoms or minor stroke, does immediate versus delayed treatment result in improved patient outcomes?

Bottom Line

The EXPRESS study found a significant decrease in recurrent stroke within 90 days for immediate (median 1 day) treatment with specific (antiplatelet, anticoagulation, dyslipidemia and HTN) therapies versus delayed (median 20 days) treatment (ARR= 8.2%, NNT= 12).

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Diabetes Mellitus (DM) Diet

DM Diet

Clinical Question
In patients with Type 2 DM, do low fat diets compared to low carbohydrate diets lead to better patient-oriented outcomes?

Bottom Line

There are no high quality data on the efficacy of any particular diet in the treatment of Type 2 DM. Reduced energy diets appear to be more important than any particular combination of fat or carbohydrate intake. When combined with exercise, reduced energy diets lead to better glycemic control.

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Does CPM after Total Knee Arthroplasty Improve Outcomes?

CPM following TKR

Clinical Question
Does the use of Continuous Passive Motion (CPM) following total knee arthroplasty improve outcomes?

Bottom Line

The effects of continuous passive motion on active and passive knee range of motion following total knee arthroplasty are too small to be clinically relevant.

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DVT - Once Daily Low Molecular Weight Heparin

Once Daily LMWH

Clinical Question
In patients with deep venous thrombosis (DVT), does once daily (1.5 mg/kg) low molecular weight heparin (LMWH) dosing result in similar efficacy and adverse events as twice daily (1.0 mg/kg) therapy?

Bottom Line

Once daily LMWH is as effective as twice daily therapy in preventing recurrent thromboembolism and does not result in higher mortality or major bleeding.

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Early Prostate Cancer

Early Prostate Cancer

Clinical Question
Is radical prostatectomy (RP) compared to watchful waiting (WW) a more effective treatment for early prostate cancer?

Bottom Line

Compared to WW, RP appears to confer a mortality benefit in healthy men under 75 with symptomatic, localized, well- to moderately well-differentiated prostate cancer.

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Epidural Steroid Injections

Epidural Steroid Injections

Clinical Question
In patients with chronic low back pain (LBP), do epidural steroid injections (ESI’s), single or multiple, provide better pain control and reduce the need for subsequent surgery compared to traditional conservative therapy?

Bottom Line

ESI’s provide limited short term symptom relief but do not provide long term (>6 weeks) improvement in patients with sciatica or neurogenic claudication due to spinal stenosis. There are no Level 1 or 2 studies that support a multiple injection strategy for long-term symptom relief or a reduction in the rate of subsequent back surgery.

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Floppy Iris Syndrome

Floppy Iris Syndrome

Clinical Question
Is there a causal association between alpha-1 adrenergic antagonist exposure and the intraoperative floppy iris syndrome (IFIS)?

Bottom Line

While a causal relationship has not been established, an awareness of this association will allow changes in operative technique that may reduce the rate of operative complications.

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GRF Equation Alternatives

GFR Equation Alternatives

Clinical Question
Is the alternative CKD EPI equation for estimating GFR better at predicting patient outcomes?

Bottom Line
Estimation of GRF using the CKD EPI equation correlates better with risk assessment and patient outcomes compared to using the MDRD equation.

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Headache and Imaging

Headache and Imaging

The vast majority of patients seen in clinical practice with headache have primary headaches: migraine, tension type, and cluster. For patients with a stable headache pattern, normal neurologic exam, and the absence of red flags for secondary headaches, brain imaging has a 0.4% yield of positive findings.

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Hydroquinone

Hydroquinone

Clinical Question
Do patients treated with topical formulations containing Hydroquinone (HQ) experience increased rates of exogenous ochronosis, leukemia or lymphoma?

Bottom Line

Although animal models have raised the possibility of carcinogenic potential, no human studies have demonstrated more serious toxicity.

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iFOB Test

iFOB Test

Clinical Question
In patients undergoing CRC screening, is immune fecal occult blood (iFOB) testing with HemeSelect®, compared to current Dean Clinic FOBT (Hemoccult II Sensa®) associated with better patient-oriented outcomes?

Bottom Line

iFOB has greater specificity but less sensitivity than Hemoccult II Sensa®. To our knowledge, there are no prospective studies addressing whether this approach leads to decreased CRC or overall mortality.

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Intensive Blood Glucose Control in Type 2 Diabetes

Intensive Blood Glucose Control

Clinical Question
In patients with type 2 diabetes does intensive therapy (goal: A1c < 7) compared to conventional therapy (goal: A1c < 8) result in improved patient-oriented outcomes?

Bottom Line

Not necessarily. Intensive therapy to lower A1c below 7 can have benefits (decreased retinal laser treatments) but can also have risks (weight gain, severe hypoglycemia, increased hospitalization and even death in one study).

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Intensive Statin Rx

Intensive Statin Rx

Clinical Question
In patients with coronary heart disease (CHD), does high dose statin therapy provide greater clinical benefit compared to regular dose statin therapy?

Bottom Line

The cited meta-analysis does not demonstrate a mortality benefit with the use of intensive statin therapy compared to regular statin therapy for CHD patients, but it does show a consistent clinical benefit in terms of reduced cardiovascular events.

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Lab Testing During Complete Physicals

Lab Testing During Complete Physicals

The purpose of this Pearl is to stimulate discussion among physicians about the value of laboratory testing.

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Why Lotrisone Is Seldom the Best Choice

Why Lotrison Is Seldom the Best Choice

Lotrisone (and generic equivalents) are among the most widely prescribed topical medications in the United States. There are several reasons why Lotrisone is seldom the treatment of choice.

Bottom Line
Avoid Lotrisone to reduce costs, side effects and treatment confusion. Make your best diagnosis and then treat accordingly.

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Methotrexate

Methotrexate

Clinical Question
Should patients on methotrexate (MTX) therapy be monitored at a specific and consistent interval?

Bottom Line

It is unclear whether liver test monitoring in the setting of MTX therapy should be standardized across different departments that are using it for different disease entities.

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MRI and Hardware Safety

MRI and Hardware Safety

Clinical Question
Do patients with cardiac rhythm management devices have an absolute contraindication to MRI scanning?

Bottom Line

Given the potential for significant adverse events such as lead heating, arrhythmogenesis, and device movement, further study is required before endorsing use of MRI in patients with pacemakers or ICDs.

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MRI Imaging and Low Back Pain

MRI Imaging and Low Back Pain

MRI imaging of the lumbar spine is costly and frequently over utilized during the evaluation of acute low back pain of a less than six week duration.

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Mumps Algorithm

Mumps Algorithm

Clinical Question
What is the Dean Health System consensus on the approach to the patient with suspected mumps?

Bottom Line

See algorithm.

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NMR Lipoprofile

NMR Lipoprofile

Clinical Question
Should NMR lipoprofile be clinically used to assess cardiovascular risk?

Bottom Line

At this time, there is insufficient evidence to show that NMR lipoprofile should be used for routine cardiovascular risk screening.

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NSAID GI Toxicity

NSAID GI Toxicity

Clinical Question
Do patients taking prolonged non-steroidal anti-inflammatory drugs (NSAIDs) and gastro-protective medications experience fewer adverse gastrointestinal (GI) complications as compared to patients taking NSAIDs who do not take gastro-protective medications?

Bottom Line

Gastro-protective medications reduce the risk of NSAID induced peptic ulcer disease in high risk patients. If NSAIDs are used in high risk patients, the lowest effective NSAID dose should be used with a mucosoprotective agent such as omeprazole 20 mg qd. 

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Perioperative Statin Use

Perioperative Statin Use

Clinical Question
Should patients discontinue statins prior to general anesthesia in order to prevent rhabdomyolysis or other complications?

Bottom Line

Pre-operative exam physicians should advise patients taking statins and contemplating major surgery to continue statins unless there are other risk factors that could contribute to rhabdomyolysis.

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Pertussis

Pertussis Algorithm

Clinical Question
What is the DHS consensus on the approach to the patient with suspected pertussis?

Bottom Line

See algorithm.

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PETs for OME

PETs for OME

Clinical Question
In pediatric patients with otitis media with effusion (OME), does insertion of tympanastomy tubes compared to conservative (non-operative) management result in improved hearing and developmental outcomes?

Bottom Line

Although short term gains in hearing have been noted, tympanostomy tube insertion compared to conservative management has not been shown to result in long term improvements in speech and language development.

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Post CABG/PCI Cardiac Testing

Post CABG/PCI Cardiac Testing

Clinical Question
In patients who have undergone percutaneous coronary intervention (PCI) or coronary artery bypass surgery (CABG) and who remain asymptomatic, does regular periodic exercise testing result in improved patient outcomes?

Bottom Line

There is no evidence that a strategy of regular periodic exercise testing improves patient-oriented outcomes.

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PPI Use and Hip Fracture

PPI Use and Hip Fracture

Clinical Question
Are patients on long term acid suppression therapy, compared to patients not receiving such therapy, at increased risk of developing hip fractures?

Bottom Line

A causal association between long term acid suppression therapy and hip fracture has not been established.

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Preoperative Laboratory Testing

Preoperative Laboratory Testing

In 2005, Dean charged over $2.1 million on preoperative laboratory testing.
Preoperative laboratory testing in healthy asymptomatic adults does not decrease the risk of surgery or result in any improvement in patient outcomes.

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Primary Prevention of Heart Disease

Primary Prevention of Heart Disease

Clinical Question
Does treatment with a statin reduce CV events in patients without CV disease but with CV risk factors (Primary Prevention)?

Bottom Line

The key finding of the meta-analysis referenced above is that the statin trials consistently demonstrate a relative risk reduction (RRR) in cardiovascular events and all cause mortality in patients without previous CV disease but with CV risk factors.

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Procalcitonin Testing for Acute Respiratory Illness

Procalcitonin Testing

Clinical Question
In primary care outpatients with acute respiratory illnesses, does obtaining a procalcitonin level result in improved patient-oriented outcomes?

Bottom Line

Procalcitonin testing in the primary care setting to help decide whether to prescribe antibiotics cannot be recommended based on current evidence.

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PT and Low Back Pain

PT and LBP

Clinical Question
Do patients with low back pain who undergo physical therapy have better outcomes than those who are encouraged to pursue a self-paced fitness program or given an advice booklet in the office?

Bottom Line

Physical therapy provides no advantage in functional recovery.

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Renal Artery Stenosis (RAS) and Stenting

RAS and Stenting
AHRQ RAS Clinician Guide

Clinical Question
In patients with hypertension and atherosclerotic renal artery stenosis (RAS), does percutaneous transluminal renal artery angioplasty plus stenting (PTRA-S) improve renal function, blood pressure control or mortality compared to aggressive medical therapy alone?

Bottom Line

It remains unclear whether percutaneous transluminal renal artery angioplasty plus stenting (PTRA-S) provides more clinical benefit than aggressive medical therapy alone. The identification of patients with RAS who are considered appropriate candidates for PTRA-S is currently based on expert opinion.

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Robotic Surgery

Robotic Surgery 

Clinical Question 
Does Robotic Surgery offer benefits in patient care?


Bottom Line

Robotically assisted surgery may offer certain advantages as a less invasive procedure compared to an open procedure as well as in technically difficult to perform laparoscopy cases. However, the costs are higher and the potential benefits are not necessarily obtained in a community setting. Definite improved clinical outcomes have not been proven. 

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RST - A Negative Rapid Strep Test (RST) in Adults Does Not Require A Routine Confirmatory Throat Culture

RST - A Negative Rapid Strep Test (RST) in Adults Does Not Require A Routine Confirmatory Throat Culture

The use of a rapid strep test (RST) alone (or a throat culture alone) is sufficient for the management of patients > 18 years of age suspected of having strep pharyngitis.

Bottom Line
Eliminate a confirmatory throat culture in patients > 18 years of age by ordering a RST alone.

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Simvastatin - Use of Generic Simvastatin will Result in Higher Value of Care for Most Patients Requiring Statin Therapy

Simvastatin - Use of Generic Simvastatin will Result in Higher Value of Care for Most Patients Requiring Statin Therapy

With patients paying a much lower co pay for generics, switching patients from a branded statin to a generic statin represents a true “win-win” situation.

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Spirometry (Asthma) CPA

Spirometry (Asthma) CPA

Clinical Question
In the routine primary care management of asthma patients, does the addition of point-of-care spirometry in the primary care office, compared to referral spirometry, result in better patient-oriented outcomes?

Bottom Line

Patient-oriented effectiveness studies comparing point-of-care spirometry in the primary care office to referral spirometry have not been performed.

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SSRI Treatment for Major Depression

SSRI Treatment for Major Depression

Clinical trials of the five most frequently prescribed SSRIs (citalopram, escitalopram, fluoxetine, paroxetine, and sertraline) do not show differences in efficacy. Rates of response, remission, and discontinuation do not differ substantially among the drugs.

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Tamoxifen

Tamoxifen

Clinical Question
In women taking tamoxifen, does the use of SSRIs (and other agents) that strongly inhibit CYP2D6, compared to the use of weaker inhibitors of CYP2D6, result in worse patient oriented outcomes such as mortality, time-to-recurrence, or relapse free survival?

Bottom Line

Although the evidence is not conclusive, it seems prudent to avoid prescribing strong CYP2D6 inhibitors such as fluoxetine, paroxetine, bupropion, and quinidine in tamoxifen-treated women.

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Target LDL in Patients with Ischemic Vascular Disease

Target LDL in Patients with Ischemic Vascular Disease

IVD and Statin Trials - Appendix

Clinical Question
Does the adoption of a target LDL < 100 mg/dL for all patients with ischemic vascular disease (IVD) result in improved patient-oriented outcomes? 

Bottom Line

Clinicians treating IVD patients should consider the NCEP ATP-III recommended LDL target of less than 100 mg/dL as a minimum therapeutic goal. Lowering LDL cholesterol further below 100 mg/dL may result in even greater reductions in the risk of future coronary events. In general, statin therapy for secondary prevention should be increased as much as possible toward maximal doses.

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Thyroid Screen for Diabetes Mellitus (DM) and Depression

Thyroid Screen for DM and Depression

Clinical Question
In depressed diabetics, does systematic screening for thyroid disease produce superior outcomes compared to symptom-based case finding or to no screening?

Bottom Line

Evidence is insufficient to recommend systematic screening for thyroid disease in any chronic disease subgroup, including depressed diabetics.

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Treating Barrett’s with Radiofrequency Ablation

Treating Barrett’s with Radiofrequency Ablation

Clinical Question
Does the use of radiofrequency ablation for the management of Barrett’s esophagus with low-grade dysplasia compared to standard management lead to decreased mortality or other improved patient outcomes?s? 

Bottom Line

One clinical trial demonstrated a higher rate of complete ablation and reduced disease progression to cancer compared to sham procedure. This was a fairly small study however, and a shift of a single incident cancer would have resulted in a loss of statistical significance. These results should therefore be interpreted with caution. There are no long-term data regarding patient outcomes.

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Treating Urinary Incontinence with PTNS

PTNS

Clinical Question
In patients with urinary incontinence does posterior tibial nerve stimulation (PTNS) compared to placebo or anticholinergic drugs result in improved patient outcomes?

Bottom line
PTNS is effective in the treatment of women with urinary incontinence who are intolerant or failed anticholinergic drug therapy.

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Virtual Colonoscopy

Virtual Colonoscopy

Virtual Colonoscopy - Patient Education

Clinical Question
In a general patient population undergoing colorectal cancer (CRC) screening is virtual colonoscopy superior to standard colonoscopy in detection of polyps, patient comfort, or cost?

Bottom Line

It is too early to recommend virtual colonoscopy for the general patient population.

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Very Low Calorie Diet and Weight Loss

VLCD and Weight Loss

Clinical Question
In obese patients (BMI >30), does one particular very low calorie diet (VLCD) achieve superior results with regard to weight loss maintenance?

Bottom Line

Taken together, the evidence is insufficient to recommend one specific VLCD over another.

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VTE Prophylaxis After Knee or Hip Surgery

VTE Prophylaxis After Knee or Hip Surgery

Clinical Question
Are any of the currently available anti-thrombotic strategies superior in the prevention of thromboembolic complications of major lower extremity orthopedic surgery?

Bottom Line

The use of aspirin alone is a Grade 1A recommendation against. For the specific recommended combinations of LMWH and warfarin see VTE PDF document.

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