Lipid-lowering therapies for cardiovascular disease prevention and management in primary care: PEER umbrella systematic review of systematic reviews.

OBJECTIVE: To assess the benefits and harms of lipid-lowering therapies used to prevent or manage cardiovascular disease including bile acid sequestrants (BAS), ezetimibe, fibrates, niacin, omega-3 supplements, proprotein convertase subtilisin-kexin type 9 (PCSK9) inhibitors, and statins. DATA SOURCES: MEDLINE, the Cochrane Database of Systematic Reviews, and a grey literature search. STUDY SELECTION: Systematic reviews of randomized controlled trials published between January 2017 and March 2022 looking at statins, ezetimibe, PCSK9 inhibitors, fibrates, BAS, niacin, and omega-3 supplements for preventing cardiovascular outcomes were selected. Outcomes of interest included major adverse cardiovascular events (MACE), cardiovascular mortality, all-cause mortality, and adverse events. SYNTHESIS: A total of 76 systematic reviews were included. Four randomized controlled trials were also included for BAS because no efficacy systematic review was identified. Statins significantly reduced MACE (6 systematic reviews; median risk ratio [RR]=0.74; interquartile range [IQR]=0.71 to 0.76), cardiovascular mortality (7 systematic reviews; median RR=0.85, IQR=0.83 to 0.86), and all-cause mortality (8 systematic reviews; median RR=0.91, IQR=0.88 to 0.92). Major adverse cardiovascular events were also significantly reduced by ezetimibe (3 systematic reviews; median RR=0.93, IQR=0.93 to 0.94), PCSK9 inhibitors (14 systematic reviews; median RR=0.84, IQR=0.83 to 0.87), and fibrates (2 systematic reviews; mean RR=0.86), but these interventions had no effect on cardiovascular or all-cause mortality. Fibrates had no effect on any cardiovascular outcomes when added to a statin. Omega-3 combination supplements had no effect on MACE or all-cause mortality but significantly reduced cardiovascular mortality (5 systematic reviews; median RR=0.93, IQR=0.93 to 0.94). Eicosapentaenoic acid ethyl ester alone significantly reduced MACE (1 systematic review, RR=0.78) and cardiovascular mortality (2 systematic reviews; RRs of 0.82 and 0.82). In primary cardiovascular prevention, only statins showed consistent benefits on MACE (6 systematic reviews; median RR=0.75, IQR=0.73 to 0.78), cardiovascularall-cause mortality (7 systematic reviews, median RR=0.83, IQR=0.81 to 0.90), and all-cause mortality (8 systematic reviews; median RR=0.91, IQR=0.87 to 0.91). CONCLUSION: Statins have the most consistent evidence for the prevention of cardiovascular complications with a relative risk reduction of about 25% for MACE and 10% to 15% for mortality. The addition of ezetimibe, a PCSK9 inhibitor, or eicosapentaenoic acid ethyl ester to a statin provides additional MACE risk reduction but has no effect on all-cause mortality.

PEER simplified lipid guideline 2023 update: Prevention and management of cardiovascular disease in primary care.

OBJECTIVE: To update the 2015 clinical practice guideline and provide a simplified approach to lipid management in the prevention of cardiovascular disease (CVD) for primary care. METHODS: Following the Institute of Medicine's Clinical Practice Guidelines We Can Trust, a multidisciplinary, pan-Canadian guideline panel was formed. This panel was represented by primary care providers, free from conflicts of interest with industry, and included the patient perspective. A separate scientific evidence team performed evidence reviews on statins, ezetimibe, proprotein convertase subtilisin-kexin type 9 inhibitors, fibrates, bile acid sequestrants, niacin, and omega-3 supplements (docosahexaenoic acid with eicosapentaenoic acid [EPA] or EPA ethyl ester alone [icosapent]), as well as on 11 supplemental questions. Recommendations were finalized by the guideline panel through use of the Grading of Recommendations Assessment, Development and Evaluation methodology. RECOMMENDATIONS: All recommendations are presented in a patient-centred manner designed with the needs of family physicians and other primary care providers in mind. Many recommendations are similar to those published in 2015. Statins remain first-line therapy for both primary and secondary CVD prevention, and the Mediterranean diet and physical activity are recommended to reduce cardiovascular risk (primary and secondary prevention). The guideline panel recommended against using lipoprotein a, apolipoprotein B, or coronary artery calcium levels when assessing cardiovascular risk, and recommended against targeting specific lipid levels. The team also reviewed new evidence pertaining to omega-3 fatty acids (including EPA ethyl ester [icosapent]) and proprotein convertase subtilisin-kexin type 9 inhibitors, and outlined when to engage in informed shared decision making with patients on interventions to lower cardiovascular risk. CONCLUSION: These updated evidence-based guidelines provide a simplified approach to lipid management for the prevention and management of CVD. These guidelines were created by and for primary health care professionals and their patients.

Optimising the educational value of indirect patient care.

INTRODUCTION: Indirect patient care activities (IPCA) such as documentation, reviewing investigations and filling out forms require an increasing amount of physician time. While an essential part of patient care, rising rates of IPCA work correspond with increases in physician burnout and job dissatisfaction. It is not known how best to prepare residents in IPCA-heavy specialties (e.g. family medicine) for this aspect of their career. This study investigates how educators and residency programmes can optimise IPCA work during residency to best prepare residents for future practice. METHODS: Using Constructivist Grounded Theory, we conducted focus groups and individual interviews with 42 clinicians (19 family medicine residents, 16 family physicians in the first 5 years of practice and 7 family physician educators). All participants were connected to one family medicine residency programme. We analysed interview data iteratively, using a staged approach to constant comparative analysis. RESULTS: While residents, early career physicians and educators perceived the educational value of IPCAs differently, they all reported IPCAs as a necessary weight that family physicians carry throughout their career. Some residents described IPCAs as a burden, creating inequities in workload and interfering with other learning and personal opportunities. In contrast, educators conceptualised IPCAs as an opportunity to build and develop the skills required to carry the weight of IPCAs throughout their career. We make specific recommendations for helping residents recognise this educational opportunity, such as clarifying expectations, navigating equity, understanding purpose and maintaining consistency when teaching IPCAs. CONCLUSION: IPCAs are a key competency for many medical residents but require explicit pedagogical attention. If the educational opportunities are not made explicit, residents may miss the opportunity to develop strategies for practice management, professional boundaries, and administrative efficiencies.

PEER simplified chronic pain guideline: Management of chronic low back, osteoarthritic, and neuropathic pain in primary care.

OBJECTIVE: To develop a clinical practice guideline to support the management of chronic pain, including low back, osteoarthritic, and neuropathic pain in primary care. METHODS: The guideline was developed with an emphasis on best available evidence and shared decision-making principles. Ten health professionals (4 generalist family physicians, 1 pain management-focused family physician, 1 anesthesiologist, 1 physical therapist, 1 pharmacist, 1 nurse practitioner, and 1 psychologist), a patient representative, and a nonvoting pharmacist and guideline methodologist comprised the Guideline Committee. Member selection was based on profession, practice setting, and lack of financial conflicts of interest. The guideline process was iterative in identification of key questions, evidence review, and development of guideline recommendations. Three systematic reviews, including a total of 285 randomized controlled trials, were completed. Randomized controlled trials were included only if they reported a responder analysis (eg, how many patients achieved a 30% or greater reduction in pain). The committee directed an Evidence Team (composed of evidence experts) to address an additional 11 complementary questions. Key recommendations were derived through committee consensus. The guideline and shared decision-making tools underwent extensive review by clinicians and patients before publication. RECOMMENDATIONS: Physical activity is recommended as the foundation for managing osteoarthritis and chronic low back pain; evidence of benefit is unclear for neuropathic pain. Cognitive-behavioural therapy or mindfulness-based stress reduction are also suggested as options for managing chronic pain. Treatments for which there is clear, unclear, or no benefit are outlined for each condition. Treatments for which harms likely outweigh benefits for all or most conditions studied include opioids and cannabinoids. CONCLUSION: This guideline for the management of chronic pain, including osteoarthritis, low back pain, and neuropathic pain, highlights best available evidence including both benefits and harms for a number of treatment interventions. A strong recommendation for exercise as the primary treatment for chronic osteoarthritic and low back pain is made based on demonstrated long-term evidence of benefit. This information is intended to assist with, not dictate, shared decision making with patients.

Top 2020 studies relevant to primary care: From the PEER team.

OBJECTIVE: To summarize high-quality studies for 10 topics from 2020 that have strong relevance to primary care practice. SELECTING THE EVIDENCE: Study selection involved routine literature surveillance by a group of primary health care professionals. This included screening abstracts of high-impact journals and EvidenceAlerts, as well as searching the American College of Physicians Journal Club. MAIN MESSAGE: Topics of the 2020 articles most likely to affect primary care practice included whether antibiotic prophylaxis reduces maternal infections following operative vaginal birth; which second-line agent after metformin reduces cardiovascular outcomes for patients with diabetes; whether gabapentin is effective for alcohol use disorder; whether compression stockings prevent recurrent cellulitis; guideline recommendations for management of dyslipidemia to reduce cardiovascular risk; whether intermittent fasting is superior to consistent mealtimes for weight loss; whether vitamin C added to iron supplementation increases hemoglobin more than iron alone; whether antacid-lidocaine combinations are superior to antacid alone for epigastric pain; whether dapagliflozin improves renal and cardiovascular outcomes in chronic kidney disease; and whether empagliflozin improves cardiovascular outcomes in patients with heart failure. Five "runner-up" studies are also briefly reviewed. CONCLUSION: Research from 2020 produced several high-quality studies in diabetes and cardiovascular disease, but also included a variety of other conditions relevant to primary care such as vaginal operative births, alcohol use disorder, weight loss, and chronic leg edema.

Lignes directrices simplifiées de PEER sur les lipides : actualisation 2023: Prévention et prise en charge des maladies cardiovasculaires en soins primaires.

OBJECTIF: Actualiser le guide de pratique clinique de 2015 et présenter une approche simplifiée de la prise en charge des lipides dans la prévention des maladies cardiovasculaires (MCV) en première ligne. MÉTHODES: Conformément aux recommandations de l'Institute of Medicine dans Clinical Practice Guidelines We Can Trust, un panel pancanadien d'experts multidisciplinaires en lignes directrices a été formé. Ce panel était représentatif des cliniciens en soins primaires, libre de tout conflit d'intérêts avec l'industrie, et il tenait compte des points de vue des patients. Une équipe distincte, responsable des données probantes scientifiques, a passé en revue l'information sur les statines, l'ézétimibe, les inhibiteurs de la proprotéine convertase subtilisine-kexine de type 9, les fibrates, les chélateurs des acides biliaires, la niacine et les suppléments d'omega-3 (acide docosahexaénoïque avec acide eicosapentaénoïque [EPA] ou ester éthylique de l'EPA seul [icosapent]), ainsi que sur la réponse à 11 questions supplémentaires. Le panel des lignes directrices a finalisé les recommandations en utilisant la méthodologie GRADE (Grading of Recommendations Assessment, Development and Evaluation). RECOMMANDATIONS: Toutes les recommandations sont présentées de manière à être centrées sur le patient et conçues en ayant à l'esprit les besoins des médecins de famille et des autres cliniciens des soins primaires. De nombreuses recommandations sont semblables à celles publiées en 2015. Les statines demeurent le traitement de première intention pour la prévention tant primaire que secondaire des MCV, et le régime méditerranéen et l'activité physique sont recommandés pour réduire le risque cardiovasculaire (en prévention primaire et secondaire). Le panel des lignes directrices a recommandé de ne pas utiliser le dosage des lipoprotéines a, des apolipoprotéines B ou le score calcique coronarien (SCC) dans l'évaluation du risque cardiovasculaire, et de ne pas cibler de seuils précis de taux lipidiques. L'équipe a aussi passé en revue de nouvelles données concernant les acides gras omega-3 (y compris l'ester éthylique d'EAP [icosapent]) et les inhibiteurs de la proprotéine convertase subtilisine-kexine de type 9, et a précisé les moments où il convient de procéder à une prise de décision partagée avec les patients sur les interventions pour diminuer le risque cardiovasculaire. CONCLUSION: Ces lignes directrices actualisées et fondées sur des données probantes présentent une approche simplifiée de la prise en charge des lipides pour la prévention et le traitement des MCV. Ce guide de pratique clinique a été conçu par et pour des professionnels de la santé en soins primaires et leurs patients.

Lignes directrices simplifiées de PEER sur la douleur chronique: Gestion de la douleur chronique lombaire, arthrosique et neuropathique en première ligne.

OBJECTIF: Formuler des lignes directrices de pratique clinique pour soutenir la prise en charge de la douleur chronique, y compris la douleur lombaire, arthrosique et neuropathique, dans les soins primaires. MÉTHODES: Ces lignes directrices ont été élaborées en mettant l'accent sur les meilleures données probantes disponibles et sur les principes de décision partagée. Dix professionnels de la santé (4 omnipraticiens, 1 médecin de famille spécialisée en gestion de la douleur, 1 anesthésiste, 1 physiothérapeute, 1 pharmacienne, 1 infirmière praticienne et 1 psychologue), 1 représentant des patients, et 1 pharmacienne et spécialiste de la méthodologie des lignes directrices sans droit de vote composaient le comité des lignes directrices. Les membres ont été sélectionnés en fonction de leur profession, de leur milieu de pratique, et de l'absence d'un conflit d'intérêts de nature financière. Les lignes directrices sont le fruit d'un processus itératif incluant la détermination des questions clés, l'examen des données probantes et la formulation des recommandations des lignes directrices. Trois revues systématiques, totalisant 285 études avec répartition aléatoire et contrôlées ont été réalisées. Ces études n'étaient incluses que si elles avaient rapporté une analyse des répondants (p. ex. combien de patients ont obtenu un soulagement d'au moins 30% de la douleur). Le comité a confié à une équipe d'examen des données (composée de spécialistes des données probantes) la tâche de répondre à 11 autres questions complémentaires. Les principales recommandations découlent d'un consensus au sein du comité. Des cliniciens et des patients ont minutieusement examiné les lignes directrices et les outils de décision partagée avant leur publication. RECOMMANDATIONS: L'activité physique est recommandée comme fondement de la gestion de la douleur arthrosique et lombaire chronique; les données probantes étayant un bienfait ne sont pas concluantes dans le cas de la douleur neuropathique. La thérapie cognitivo-comportementale ou la réduction du stress basée sur la pleine conscience sont également suggérées comme des options pour gérer la douleur chronique. Les traitements pour lesquels le bienfait est clair, non concluant ou absent sont décrits sous chaque affection. Les traitements dont les préjudices surpassent probablement les bienfaits pour toutes les affections étudiées, ou la plupart d'entre elles, sont les opioïdes et les cannabinoïdes. CONCLUSION: Ces lignes directrices sur la gestion de la douleur chronique, y compris la douleur arthrosique, lombaire et neuropathique, met en lumière les meilleures données probantes disponibles, y compris les bienfaits et préjudices pour un certain nombre d'interventions thérapeutiques. Une forte recommandation en faveur de l'exercice comme principal traitement de la douleur arthrosique et lombaire chronique repose sur des données probantes ayant démontré un bienfait depuis longtemps. Cette information vise à contribuer au processus de décision partagée avec le patient et non à le dicter.

Principales études pertinentes aux soins primaires en 2020: De l'équipe du groupe PEER.

OBJECTIF: Faire la synthèse d'études de grande qualité sur 10 sujets, publiées en 2020, qui sont d'une grande pertinence pour la pratique des soins primaires. SÉLECTION DES DONNÉES PROBANTES: La sélection des études s'est faite à la suite d'une surveillance systématique de la littérature scientifique par un groupe de professionnels de la santé en soins primaires. Les résumés de revues à fort impact et les EvidenceAlerts ont été dépouillés, de même que l'American College of Physicians Journal Club. MESSAGE PRINCIPAL: Au nombre des articles en 2020 qui influenceront fort probablement la pratique des soins primaires figurent ceux portant sur les questions suivantes : l'antibioprophylaxie réduit-elle les infections maternelles à la suite d'un accouchement vaginal opératoire? Quel agent de deuxième intention après la metformine réduit les risques cardiovasculaires chez les patients diabétiques? La gabapentine est-elle efficace pour les troubles liés à la consommation d'alcool? Les bas de contention préviennent-ils la cellulite récurrente? Le jeûne intermittent est-il supérieur à des repas à heures régulières pour perdre du poids? La vitamine C ajoutée aux suppléments de fer augmente-t-elle plus l'hémoglobine que le fer seul? Les combinaisons d'antiacides et de lidocaïne sont-elles supérieures aux antiacides seuls pour la douleur épigastrique? La dapagliflozine améliore-t-elle les issues rénales et cardiovasculaires dans les cas de néphropathie chronique? L'empagliflozine améliore-t-elle les résultats cardiovasculaires chez les patients souffrant d'insuffisance cardiaque? Cinq sujets d'intérêt additionnels sont aussi passés brièvement en revue. CONCLUSION: La recherche a produit en 2020 plusieurs études de grande qualité sur le diabète et les maladies cardiovasculaires, de même que sur divers autres problèmes pertinents en soins primaires, comme les accouchements vaginaux opératoires, les troubles liés à la consommation d'alcool, la perte pondérale et l'œdème chronique des jambes.

Posture and Loading in the Pathomechanics of Carpal Tunnel Syndrome: A Review.

Carpal tunnel syndrome is a neuropathy of the median nerve at the wrist, and represents the most common peripheral neuropathy. It has long been an issue in the workplace because of healthcare costs and loss of productivity. The two main pathomechanisms of carpal tunnel syndrome include increased hydrostatic pressure within the carpal tunnel (carpal tunnel pressure) and contact stress (or impingement). As most cases of carpal tunnel syndrome in the workplace are labelled "idiopathic", a clear understanding of the physical parameters that may act as pathomechanisms is critical for its prevention. The aim of this review is to examine and quantify the influence of posture and loading factors on the increase of carpal tunnel pressure and median nerve contact stress. Forearm, wrist, and finger postures, as well as fingertip force have significant effects on carpal tunnel pressure. Contact stress on the median nerve is mainly a product of wrist posture and musculotendinous loading. Anatomical and musculoskeletal sources have been proposed to explain these effects. This critical review provides an improved understanding of pathomechanisms and etiology underlying carpal tunnel syndrome.