significant change was noted in HDL.

The results were

not affected by the type of intervention, treatment dose
of tea catechins, study duration, or individual health
status.

A prospective cohort trial evaluated the relationship
between daily intake of coffee, green, black and oolong
teas and risk of mortality from CVD in 82,655 Japanese
patients (34,345 men, 48,310 women; age range
4079 years) who were free of stroke, coronary heart
disease, or cancer at study entry.3 In women, higher
green tea consumption (>6 cups per day) compared with
nondrinkers consistently decreased the risk of mortality
from stroke and coronary heart disease, but not lower
amounts (16 cups per week, n=139; HR1.1; 95% CI,
0.661.9; 12 cups per day, n=154; HR 0.77; 95% CI,
0.481.3; 35 cups per day, n=598; HR 0.81; 95% CI,
0.561.2; and 6 cups per day, n=356; HR 0.62; 95%
CI, 0.40.98). No statistically significant association
was noted with the amount of green tea consumed and
decreased CVD mortality in men.
Trang Son, MD
Inyanga Mack-Collins, MD
Bronx Lebanon Department of Family Medicine
Bronx, NY
1. Hartley L, et al. Cochrane Database Syst Rev. 2013; (6):CD009934. [STEP 1]
2. Zheng X, et al. Am J Clin Nutr. 2011; 94(2):601610. [STEP 1]
3. Mineharu Y, et al. J Epidemiol Community Health. 2011; 65(3):230240. [STEP 2]

Are there differences in outcomes when treating

nursing home-acquired pneumonia in the
nursing facility versus the hospital?
Evidence-Based Answer
Patients with nursing home-acquired pneumonia
(NHAP) treated in the nursing home have similar rates
of mortality and similar or less functional decline,
compared with nursing home patients treated in the
hospital (SOR: B, single RCT and observational studies).
An RCT allocated 680 nursing home residents with
NHAP to a treatment protocol within the nursing home
(n=327) or to usual care (n=353) to evaluate if the use
of a clinical algorithm reduced hospitalizations.1 The
protocol intervention assigned all patients tolerating
oral nutrition and not meeting sepsis criteria to
onsite treatment with levofloxacin 500 mg orally for
10 days and hypodermoclysis to treat dehydration if

needed. The usual care group was either treated onsite

or admitted to the hospital at the discretion of the
attending physician.
Fewer patients in the protocol treatment group
needed hospitalization than in the usual care group
(34 of 327 [10%] and 76 of 353 [22%]; P=.001). No
significant mortality difference was noted at 30 days
between the 2 groups (mean difference of 2.9%; 95%
CI, 0.02 to 0.08). There was also no difference in
health-related quality of life, change in functional status,
time to stabilization of vital signs, secondary infections
(urinary, skin, or soft-tissue), or number of falls.1
A prospective cohort trial evaluated 1,406 episodes
of lower respiratory infection (pneumonia or bronchitis,
diagnosed by chest x-ray or predefined symptoms) in
nursing home patients; initial treatment was in the
hospital for 198 patients and in the nursing home for
1,208.2 After controlling for illness severity, as well as
attending physician and facility characteristics that
influenced interfacility variation in hospitalization rates,
the risk of 30-day mortality was equivalent between
similar hospital and nursing home-treated residents
(OR 0.89; 95% CI, 0.521.5).
Using the same data set from the trial above, a
second article revealed hospitalization was significantly
associated with decline in activities of daily living
(ADLs) at 30 days, defined as at least a 3-point increase
on the Minimum Data Set long form (scale 028, with
higher scores representing increased ADL dependency)
(adjusted odds ratio [aOR] 1.9; 95% CI, 1.32.1).3

Another prospective trial evaluated 4,990 infections
in 1,301 nursing home residents and compared early
transfer to the hospital (within 3 days) with initial
nursing home treatment.4 Only 12% of the infections
were lower respiratory infections, and the analysis did
not separate outcomes by infection type.
After matching patients by type of infection (such
as lower respiratory infection or skin infection) as well
as by facility characteristics and individual patient
characteristics, patients transferred to the hospital early
had increased mortality compared with patients treated
for at least the first 3 days in the nursing home (RR
1.4; 95% CI, 1.042.0). For patients surviving at least
1 month, early transfer to the hospital increased risk of
pressure ulcers (OR 1.6; 95% CI, 1.22.2).4
A retrospective cohort trial identified 312 cases
of NHAP; 246 patients were treated initially in the
long-term care facility versus 66 in the hospital.5
continued

Evidence-Based Practice / Vol. 18, No. 8

After adjusting for pneumonia severity and conditions

predictive of worsened pneumonia course, the
hospitalized group had increased combined mortality
and functional decline at 2 months (aOR 3.1; 95% CI,
1.37.2). Mortality and functional decline were not
assessed separately in the adjusted analysis.
Daniel J. Fisher, MD
Community FMR
Indianapolis, IN
1. Loeb M, et al. JAMA. 2006; 295(21):25032510. [STEP 2]
2. Kruse RL, et al. Med Care. 2004; 42(9):860870. [STEP 3]
3. Binder EF, et al. J Gerontol A Biol Sci Med Sci. 2003; 58(1):6067. [STEP 3]
4. Boockvar KS, et al. J Am Geriatr Soc. 2005; 53(4):590596. [STEP 3]
5. Fried TR, et al. J Am Geriatr Soc. 1997; 45(3):302306. [STEP 3]

What are the causes of murmurs

in young children?
Evidence-Based Answer
Structural anomalies may be found in up to 43% of
newborns with heart murmurs, although only about 5%
of newborns with murmurs require early intervention
(SOR: C, single retrospective cohort study). In older
children referred for evaluation of murmurs, 91% have
minor or no structural disease on echocardiography
(SOR: B, single retrospective cohort study). Ventricular
septal defect (VSD) and atrial septal defect (ASD)
are the most common significant anomalies in both
neonates and older children.
A retrospective cohort study performed over 4 years
evaluated 6,333 infants born at a single hospital in Saudi
Arabia not requiring immediate NICU placement.1 On
routine examination, 87 (1.4%) of the newborns were
found to have heart murmurs. All of these infants then
underwent echocardiography and 37 patients (43%)
had an underlying structural deficit. The most common
deficit was VSD (62%). Less common diagnoses
included ASD (n=5), patent ductus arteriosus (n=3),
pulmonary stenosis (n=3), pulmonary atresia (n=1),
aortic stenosis (n=1), and hypertrophic cardiomyopathy
(n=1). Five percent of infants with murmurs had a
cardiac malformation serious enough to require early
cardiac intervention.
A 5-year retrospective cohort study from the
United States examined children with asymptomatic
murmurs between the ages of 1 month and 4 years who
8

Evidence-Based Practice / August 2015

were referred for evaluation and underwent sedated

echocardiograms.2 Children were sedated to ensure
diagnostic reliability and uniform approach.
Exclusion criteria included no listed indication
for echocardiogram, multiple indications for
echocardiography, prior echocardiogram performed at
another facility, a known prenatal diagnosis of cardiac
disease, or known disease that was associated with
cardiac anomalies.2
Of the patients who met inclusion criteria (N=462),
the most common echocardiogram findings were no
abnormalities (66%), mild pulmonic stenosis (8%), and
small VSD (42%). Only 1% of children screened had
severe pathology and 8% had moderate disease, leaving
91% with mild to no disease.2
Echocardiographic abnormalities were more
common among younger age groups: 2% of children
<1 year old were found to have severe pathology and no
severe pathology was seen in children aged >1 year. The
most commonly identified moderate to severe disease
was ASD at 4.6%, followed by VSD at 2.4%. Rare
pathologies included coarctation of the aorta (n=3),
Dacron patch aortoplasty (n=2), transposition (n=1),
hypoplastic branch pulmonary arteries (n=1), mitral
regurgitation (n=1), and atrioventricular canal/double
outlet right ventricle (n=1).2
Cassidy Graham, DO
Zach Deiss, MD
University of Wyoming FPRP Casper
Casper, WY
1. Lardhi AA. J Saudi Heart Assoc. 2010; 22(1):2527. [STEP 3]
2. Kwiatkowski D, et al. Congenital Heart Dis. 2012; 7(3):283288. [STEP 3]

What is the clinical workup for failure

to thrive in infants?
Evidence-Based Answer
The workup for failure to thrive should begin with a
detailed history and physical examination. No specific
routine labs or imaging studies are recommended; any
additional workup should be guided by information
gleaned from the history and physical (SOR: C, expert
opinion).
A 2007 prospective, observational study in Copenhagen
followed 6,090 infants for 11 months to determine
which anthropometric features were most consistent