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Showing posts from November, 2015

Prospective validation of a 1-hour algorithm to rule-out and rule-in acute myocardial infarction using a high-sensitivity cardiac troponin T assay

Methodology Score: 3/5      Usefulness Score: 2/5
Reichlin T, Twerenbold R, Wildi K, et al. CMAJ May 19, 2015 187:E243-E252;
Full Article This multicenter study aiming to prospectively validate a 1 hour algorithm using a high sensitivity cardiac troponin assay classified 59.5% patients in the Rule Out group (30 day mortality was 0%), 16.4% Rule-In (30 day mortality 1.6%) and 24.1 % of patients in the Observational Group (30 day Mortality 1.9%).Limitations of this study included selection bias, incorporation bias and loss to follow-up bias. JC attendees agreed that further studies are warranted prior to applying this algorithm prospectively for clinical deci­sion-making in the ED.  By: Dr. Ayesha Zia (Presented Jun 2015)

Epi lesson: Incorporation bias

Medical expulsive therapy in adults with ureteric colic: a multicentre, randomised, placebo-controlled trial

Methodology Score: 4.5/5               Usefulness Score: 4.5/5
Pecard R, Starr K, MacLennan G, Lam T, et al. Published Online May 19, 2015 http://dx.doi.org/10.1016/S0140-6736(15)60933-3
Full Article
This high quality multicenter, randomized, triple-blind, placebo-controlled study of almost 1,200 adult patients with CT confirmed solitary ureteral stone (<10mm) found no statistically significant differences in using either Tamsulosin or Nifedipine vs placebo for the purposes of preventing urologic intervention at 4wks. Analgesic use, time to stone passage, and overall health status were similar in all three groups. JC attendees found few flaws in this study which should deter emergency physicians from needlessly prescribing these medications in cases of ureterolithiasis.  By: Dr. Tamara McColl (Presented June 2015)

Epi lesson:  Stratification of Randomization to Adjust for Confounding

Improving attendance at post-emergency department follow-up via automated text message appointment reminders: a randomized controlled trial

Methodology Score: 3.5/5              Usefulness Score:  3/5
Arora S, Burner E, Terp S, Nok Lam C, Nercisian A, Bhatt V, Menchine M. Acad Emerg Med. 2015 Jan;22(1):31-7.
Full Article
In this single-center, open label RCT of 374 patients, a per-protocol analysis demonstrated that text message appointment reminders improved post-ED follow-up compliance with an NNT of 9.5 (difference between groups=10.5%, 95%CI:0.3%-20.8%). Unfortunately, the study was underpowered for the primary outcome, lacked assessment of important confounders to follow-up compliance and feasibility at TOH would not be possible given our current appointment booking system.  By: Dr. Nicholas Costain

Epi lesson: Random sampling vs Randomization

Lactulose vs polyethylene glycol 3350--electrolyte solution for treatment of overt hepatic encephalopathy: the HELP randomized clinical trial

Methodology Score: 3/5                  Usefulness Score: 2.5/5
Rahimi RS, Singal AG, Cuthbert JA, Rockey DC. JAMA Intern Med. 2014 Nov;174(11):1727-33 Full Article

Editorial: Polyethylene Glycol for Hepatic Encephalopathy Polyethylene A New Solution to Purge an Old Problem? Doran AE, Shah NL JAMA Intern Med. 2014;174(11):1734-1735 Editorial Link
This small, non-blinded, government funded, randomized trial found that PEG was significantly more effective than lactulose for the treatment of acute hepatic encephalopathy (NNT 3.5 to produce a significant positive change in the hepatic encephalopathy score).  However, methodological limitations (small n, non-blinded, per-protocol analysis, no follow up) currently limit its applicability in the ED - look for future studies of PEG in the treatment of acute hepatic encephalopathy.

Systemic inflammatory response syndrome criteria in defining severe sepsis

Methodology Score: 4/5                  Usefulness Score: 3.5/5
Kaukonen KM, Bailey M, Pilcher D, et al. N Engl J Med. 2015 Apr 23;372(17):1629-38.
Full Article
This retrospective multicenter study found that the use of SIRS criteria to define severe sepsis within 24 hours of admission to the ICU has poor sensitivity and construct validity, with 1 in 8 patients presenting with <2 criteria and substantial mortality rates; there was also a linear increase in the risk of death with the presence of each additional SIRS criterion, suggesting that the consensus cutoff of 2 may not be valid. The group agreed that the included population may not reflect all-comers with severe sepsis to the ED and that further studies are needed to define the characteristics of patients presenting with SIRS-negative severe sepsis.  By: Dr. Lauren Lacroix (Presented May 2015)

Epi lesson: Characteristics of a Good Article About Prognosis As described in the iconic JAMA publication, User’s Guide to the Medical Litera…