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Showing posts from September, 2014

Short-term vs Conventional Glucocorticoid Therapy in Acute Exacerbations of Chronic Obstructive Pulmonary Disease The REDUCE Randomized Clinical Trial

Methodology Score: 4/5                 Usefulness Score: 4/5
Leuppi JD, et al. JAMA. 2013 Jun 5;309(21):2223-31.
Article Link
This multicenter, double blinded trial demonstrated non-inferiority of a 5-day course of 40mg prednisone versus a 14-day course of 40mg prednisone in the treatment of patients admitted to hospital for acute exacerbation of COPD (AECOPD). Although the patient population was not identical to the ED population, the group agrees that these results should encourage ED physicians to prescribe a 5 day course of prednisone for uncomplicated AECOPD.  By: Dr. Christopher Mong (Presented April 2014)

Epi lesson: Non-inferiority Trials

Albumin replacement in patients with severe sepsis or septic shock

Methodology Score: 3.5/5              Usefulness Score: 2.5/5
Caironi P, Tognoni G, et al. the ALBIOS Study Investigators. N Engl J Med. 2014 Mar 18.
Abstract Link
This was an open-label RCT of 1,800 ICU patients with severe sepsis or septic shock, examining whether targeting a certain serum albumin level with albumin supplementation improved: mortality at 28 and 90 days, presence and degree of organ dysfunction, and length of stay in hospital and in ICU.  Giving albumin vs. saline did not improve any of these a priori outcomes.  JC attendees agreed that while the study was well-designed, it had a significant amount of crossover with no sensitivity analysis, and targeting a serum albumin concentration in the ED is not practical.  By: Dr. Ashley Krywenky
(April 2014)

Epi lesson: Stratification of Randomization by Timing of Enrolment
Block randomization offers the benefit of ensuring overall balance of groups when you have multiple centers or clinically defined subgroups. Another approach is to …

Impact Factors for Emergency Medicine and Other Popular Journals

The impact factor (IF) of  scientific journal reflects the average number of citations to recent articles published in the journal. It is used as a proxy for the relative importance of a journal, with journals with higher impact factors deemed to be more important than those with lower ones. Impact factors are calculated yearly for those journals that are indexed in the Journal Citation Reports. The impact factor has limitations and other measures have been proposed. Regardless, the IF does provide an estimate of the relative strength of various journals overall and within a specific field.

Post by Dr. Ian Stiell OHRI - Profile @EMO_daddy


Journal Data Filtered By:  Selected JCR Year: 2013 Selected Editions: SCIE Source: InCites Journal Citation Reports

Accuracy of single progesterone test to predict early pregnancy outcome in women with pain or bleeding: meta-analysis of cohort studies

Methodology Score: 4/5                 Usefulness Score: 2/5
Verhaegen J, Gallos ID, van Mello NM, Abdel-Aziz M, Takwoingi Y, Harb H, Deeks JJ, Mol BW, Coomarasamy A BMJ. 2012 Sep 27;345:e6077
Article Link
This thorough and well performed systematic literature review found that a single progesterone test before 14 weeks gestational age in women with pain or bleeding and an inconclusive ultrasound could predict a viable vs. non-viable (spontaneous abortion or ectopic) pregnancy with a specificity of 98.4% and sensitivity of 74.6%. JC attendees felt that the results of this review did not support the routine use of a single progesterone for predicting non-viability given the poor sensitivity of this test and the risk of potential ectopic pregnancy in this group. Continued use of serial beta-hcgs and clinical follow-up were strongly favoured.  By: Dr. Laura Francis (Presented April 2014)

Epi lesson: Goals of Systematic Literature Reviews

Outpatient versus inpatient treatment for patients with acute pulmonary embolism: an international, open-label, randomised, non-inferiority trial

Methodology Score: 4/5  Usefulness Score:  3.5/5 Aujesky D, et al. Lancet. 2011 Jul 2;378(9785):41-8. 
Abstract Link

This open label, randomized, un-blinded, multi-centered trial compared inpatient vs. outpatient treatment of low-risk PE showed that outpatient management is non-inferior with respect to endpoints of recurrent VTE, major bleeding, and mortality. JC attendees felt the methodology was strong; however, were less in favour of the per-protocol analysis calculations used to show non-inferiority for bleeding outcomes when this was non-significant in the intention-to-treat analysis.  Overall, this study supports our current practice of outpatient management of patients with low-risk acute PE, but lacks any practice modifying findings.  By: Dr. Lindsey Forest  (Presented April 2014)

Epi lesson: Intention to Treat vs. Per Protocol Analyses

Fever Control Using External Cooling in Septic Shock: A Randomized Controlled Trial

Methodology Score: 2.5/5               Usefulness Score: 2/5
Schortgen F1, et al. Am J Respir Crit Care Med. 2012 May 15;185(10):1088-95
Full Article This randomized, non-blinded trial found in an ICU population that external cooling in febrile patients with septic shock resulted in a 50% decrease in vasopressor requirements at 12 and 24 hours, however, their data was underwhelming as their primary outcome at 48 hours was non-significant. The authors attempted to emphasize a decrease in mortality, however their study was not powered to appropriately address this. The idea of fever control in septic shock is an interesting one, but this study leaves us wanting further research, specifically a randomized trial comparing external cooling and antipyretics powered to show a mortality difference.  By: Dr. Shahbaz Syed (Presented March 2014)

Epi lesson: Clinical Equipoise