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The authors noted insufficient evidence to recommend any specific treatment or combination of treatments for varicose veins (evidence rating B “inconsistent or limited-quality patient-oriented evidence). Sclerotherapy was noted for improving the symptoms or cosmetic appearance of varicose veins (evidence rating of B).4 Megha Manek, MD Andrew Kayes, MD Michael Sidhom, MD, MSPH Michael Gillan, DO Guthrie Clinic/Robert Packer Hospital Sayre, PA 1. Shingler S, et al. Cochrane Database Syst Rev. 2011; (11):CD008819. [STEP 1] 2. Nesbitt C, et al. Cochrane Database Syst Rev. 2011; (10):CD005624. [STEP 1] 3. Tisi PV, et al. Cochrane Database Syst Rev. 2006; (4):CD001732. [STEP 1] 4. Jones R, et al. Am Fam Physician. 2008; 78(11):1289–1294. [STEP 5] Which surgical patients benefit from perioperative beta-blockers? Evidence-Based Answer In patients undergoing cardiac or vascular surgery or patients with cardiac risk factors undergoing nonvascular surgery, perioperative beta-blockers reduce 30-day risk of acute myocardial infarction (NNT=57) and 1-year mortality (NNT=28), but do not change 30-day mortality. This benefit is partially offset by increased risk of stroke (NNH=177) (SOR: A, meta-analysis of RCTs). Patients with 2 or more Revised Cardiac Risk Index (RCRI) factors taking beta-blockers have a lower 30-day mortality than patients not taking beta-blockers undergoing vascular or nonvascular surgery (SOR: B, single cohort study). A meta-analysis of 27 parallel RCTs with 13,550 patients evaluated mortality and other major outcomes in patients undergoing surgery who either stopped or added a perioperative beta-blocker.1 The trials included a variety of beta-blockers at standard doses. Surgeries were primarily cardiac or vascular with some nonvascular surgeries in patients with cardiac risk factors. The addition of a beta-blocker during the perioperative period did not change 30-day mortality compared with control groups in which most patients were not already taking a beta-blocker or beta-blockers were stopped preoperatively (12 trials, n=11,101; risk 12 Evidence-Based Practice / November 2015 ratio [RR] 0.91; 95% CI, 0.57–1.4), but did reduce mortality at 1 year (4 trials, n=781; RR 0.55; 95% CI, 0.31–0.99; NNT=28). Adding a beta-blocker also reduced the 30-day risk of acute myocardial infarction compared to similar control groups (15 trials, n=12,224; RR 0.65; 95% CI, 0.47–0.88; NNT=57), but increased the 30-day risk of stroke (8 trials, n=11,737; RR 2.2; 95% CI, 1.4–3.4; NNH=177).1 A multicenter, retrospective, cohort analysis at 104 VA medical centers from 2005 to 2010 examined perioperative beta-blocker exposure in 136,645 patients undergoing inpatient or outpatient noncardiac surgery (vascular and nonvascular).2 This trial matched patients exposed to beta-blockers 1:1 with those not exposed and adjusted for underlying conditions that would lead to beta-blocker therapy using propensity scores (37,805 pairs). The groups were substratified using the following RCRI variables: high-risk surgery, cerebrovascular disease, ischemic heart disease, congestive heart failure, diabetes mellitus, and renal insufficiency. There were significant associations between betablocker exposure and lower 30-day all-cause mortality in patients with 2 factors (RR 0.63; 95% CI, 0.50– 0.80; NNT=105), 3 factors (RR 0.54; 95% CI, 0.39– 0.73; NNT=41), and 4 or more factors (RR 0.40; 95% CI, 0.25–0.73; NNT=18) compared with patients not exposed to beta-blockers. No difference was noted in outcomes among patients with 0 or 1 risk factor. Among the matched cohorts, the incidence of stroke did not differ from between the beta-blocker group and the no beta-blocker group. The subgroup undergoing vascular surgery showed no significant change in 30-day mortality or cardiac morbidity compared with nonvascular surgery patients.2 A 2009 American College of Cardiology Foundation/American Heart Association (ACCF/AHA) policy statement recommended the continuation of beta-blockers perioperatively in patients already taking a beta-blocker (Class I recommendation, evidence obtained from at least 1 properly designed RCT).3 They recommended the use of a perioperative beta-blocker in patients with inducible ischemia, coronary artery disease, or multiple RCRI factors undergoing vascular surgery and in patients with coronary artery disease or multiple RCRI factors undergoing intermediaterisk surgery (Class IIa recommendation, evidence obtained from well-designed controlled trials without randomization). They also stated the role of perioperative betablocker treatment in low-risk patients is uncertain (Class IIb recommendation, evidence obtained from welldesigned cohort or case-control analytic studies). They did not recommend the routine use of perioperative high-dose beta-blockers (Class III recommendation, opinions of respected authorities, based on clinical experience, descriptive studies, or reports of expert committees).3 Monique Forsea, MD Philipp Narciso, MD UAMS – South FMRP Magnolia, AR 1. Guay J, et al. J Cardiothorac Vasc Anesth. 2013; 27(5):834–844. [STEP 1] 2. London MJ, et al. JAMA. 2013; 309(16):1704–1713. [STEP 3] 3.American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2009; 54(22):e13–e118. [STEP 5] What patient population is at greatest risk of having latent tuberculosis and require treatment? Evidence-Based Answer The literature does not provide guidelines on when to start treatment for latent tuberculosis (TB). Foreignborn patients should be screened and treated for latent TB infection upon diagnosis to prevent the development of active TB infections, which are most likely to occur within 2 years of arrival to the United States (SOR: B, observation and epidemiologic trials). A retrospective cohort trial examined the impact of immigration on cases of active TB in the state of Connecticut between 1995 and 2006.1 During this time, 1,152 cases of active TB were reported, 662 of which were among foreign-born persons. The incidence of active TB was much greater for foreign-born persons compared with US-born persons (20 vs 1.5 per 100,000 person-years; RR 13; 95% CI, 9.2–20). Of foreign-born persons, refugees had the highest incidence rate in the first year after US entry (116/100,000 person-years). Refugees accounted for 4% of cases among the foreign-born. This finding may have been due to overseas screening in this group. Other risk factors for developing active TB included HIV infection, a history of alcohol or drug abuse, residence in a correctional facility, and homelessness.1 Most cases of active TB are thought to be a reactivation of latent TB infection (LTBI).2 An epidemiologic analysis reviewed all active TB cases among foreign-born persons in the United States to determine which population subgroups were at the highest risk for developing active TB in order to better target screening and treatment for LTBI. From 2001 to 2006, nearly 47,000 cases of active TB among foreignborn individuals were reported. The highest rate (75 cases/100,000 persons) of active TB was within 2 years of entrance into the United States. This rate is 3 to 7 times higher than the rate of active TB diagnosed in foreign-born persons living in the United States longer than 2 years. Those entering the United States from Southeast Asia (100/100,000) and sub-Saharan Africa (250/100,000) had the highest rates of active TB. However, the rate of active TB among foreign-born individuals (10/100,000) remained higher than that of US-born persons (<2.5/100,000) after as many as 20 years after entrance into the United States (no P value provided). Case rates of active TB also increased with age among recent (<2 years) and nonrecent entrants to the United States.2 In 2000, the CDC recommended screening for LTBI in groups determined to have a high likelihood of developing active TB.3 These groups included patients born in endemic countries, those with certain medical conditions including HIV and injection drug use, and workers in high-risk settings (for example, health care workers). Screening was recommended with the tuberculin skin test. Treatment with rifampin or isoniazid was recommended for those determined to have LTBI regardless of age. Based on expert opinion, pregnant women at high risk for developing active TB should be treated with isoniazid, which should be initiated regardless of trimester. High-risk pregnant women include those who are HIV positive or have had a recent exposure to active TB. Pregnant women at low risk may defer treatment EBP until postpartum.3 Meghan Hughes, MD, MPH Jay H. Lee, MD University of Colorado FMR Denver, CO 1. Lobato MN, et al. Int J Tuberc Lung Dis. 2008; 12(5):506–512. [STEP 3] 2. Cain KP, et al. JAMA. 2008; 300(4):405–412. [STEP 3] 3.American Thoracic Society. MMWR Recomm Rep. 2000; 49(RR-6):1–51. http://www. cdc.gov/mmwr/preview/mmwrhtml/rr4906a1.htm. Accessed October 19, 2015. [STEP 5] Evidence-Based Practice / Vol. 18, No. 11 13