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Showing posts from 2013

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: 3.5/5
Leuppi JD, Schuetz P, Bingisser R, Bodmer M, Briel M, Drescher T, et al. JAMA. 2013 Jun 5;309(21):2223-31
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This multicentre, Swiss-based RCT adds to the literature that suggests a short course (5days) of corticosteroids is as effective as a longer course (14 days) for the inpatient COPD exacerbation population. JC attendees noted that almost all patients were treated as inpatients, so we cannot explicitly translate this research into outpatient management. However, it may be reasonable to consider a shorter duration of steroids in certain populations, knowing that the inpatient population did not demonstrate any additional harm and was non-inferior to standard therapy.  By: Dr. Omer Yusuf (Presented October 2013)
Epi lesson: Hazard Ratios Hazard ratios are distinct from relative risk ratios. A relative risk ratio is the expression of the number of events in a treatment group vs. control group over the duration of a tri…

How Do I Perform a Lumbar Puncture and Analyze the Results to Diagnose Bacterial Meningitis?

Landmark Article Series - UPDATE
Methodology Score: 2.5/5              Usefulness Score: 4/5 Straus SE, Thorpe KE, Holroyd-Leduc J. JAMA. 2006 Oct 25;296(16):2012-22.
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This overview article from the JAMA Rational Clinical Exam series showed a non-significant trend towards a decrease in post-LP headaches when using an atraumatic needle when performing the LP, replacing the stylet prior to removal of the LP needle, and early mobilization rather than bedrest after the procedure. They also reported guidelines for the interpretation of CSF results showing that a CSF-Blood Glucose ratio of <0.4, a CSF WBC count of >500, and a CSF lactate level of >3.5mmol/L all had very high likelihood ratios for bacterial meningitis. JC attendees expressed interest in the finding that the TOH biochemistry lab can perform CSF lactate levels upon request. By: Dr. Sameer Vakani 
(Presented October 2013)

Epi lesson: Fixed vs Random Effect Models

A 2-h diagnostic protocol to assess patients with chest pain symptoms in the Asia-Pacific region (ASPECT): a prospective observational validation study

Methodology Score: 4/5                 Usefulness Score: 3/5
Than M, Cullen L, Reid CM, Lim SH, Aldous S, Ardagh MW, et al. Lancet. 2011 Mar 26;377(9771):1077-84.
Abstract Link
This prospective multicentre cohort study attempted to validate a new 2 hour accelerated diagnostic protocol to allow rapid discharge from the emergency department for patients presenting with chest pain who had 1) a TIMI score of zero, 2) a negative ECG, and 3) negative set of point of care cardiac biomarkers at zero and 2 hours. The authors found that 9.8% of patients could have potentially been discharged after only 2 hours with a sensitivity of 99.3% for an adverse cardiac event. JC attendees felt this article introduced an interesting idea, but needs further prospective validation in a North American setting before it is ready for use.  By: Dr. Brandon Ritcey (Presented October 2013)

Epi lesson: Screening Test Sensitivity A high quality screening test is one which is highly sensitive, often at the cost of lower sp…

Intravenous Droperidol or Olanzapine as an Adjunct to Midazolam for the Acutely Agitated Patient: A Multicenter, Randomized, Double-Blind, Placebo-Controlled Clinical Trial

Methodology Score: 3/5                 Usefulness Score: 2/5
Chan EW, Taylor DM, Knott JC, Phillips GA, Castle DJ, Kong DC. Ann Emerg Med. 2013 Jan;61(1):72-81
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This randomized, double-blind, double dummy study comparing olanzepine plus midazolam or droperidol plus midazolam suggested these combinations were more effective than midazolam alone for sedation of the acutely agitated patient.  The group felt that the results of the trial could not be applied to our patient population because of the lack of assessment of the level of agitation of the patients enrolled and the lack of a validated sedation score.  By: Dr. Erin O’Connor (Presented October 2013)

Epi lesson: Validity of Measurement Tools

Validation of the Simplified Motor Score in the Out-of-Hospital Setting for the Prediction of Outcomes After Traumatic Brain Injury

Methodology score: 3/5                 Usefulness score: 2/5
Thompson DO, Hurtado TR, Liao MM, Byyny RL, Gravitz C, Haukoos JS. Ann Emerg Med. 2011 Nov;58(5):417-25
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This retrospective registry study demonstrated poor performance of either the Simplified Motor Score or GCS scores for predicting clinically important outcomes after traumatic brain injury when calculated by prehospital providers.  Journal Club attendees expressed reservations about the large proportion of missing GCS data in the study sample as well as the broader implications of losing clinically meaningful information with such a simplified score.  By: Dr. George Mastoras
(Presented September 2013)

Epi Lesson: Receiver-Operating Characteristic (ROC) Curves:
ROC curves are used to evaluate diagnostic data by plotting sensitivity versus 1-specificity, with higher areas under the curve (AUC) indicating better ability of the test to discriminate between patients with and without the condition. In this paper, the author…

Hydroxyethyl Starch 130/0.42 versus Ringer’s Acetate in Severe Sepsis

Landmark Series Methodology Score: 4/5                 Usefulness Score: 4.5/5
Perner A, et al.; 6S Trial Group; Scandinavian Critical Care Trials Group. N Engl J Med. 2012 Jul 12;367(2):124-34
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This multi-centre, double-blind, RCT found that resuscitation of severely septic patients with Hydroxyethyl Starch 130/0.42 conferred a greater risk of renal replacement therapy and of death at 90 days when compared to Ringer's acetate.  Despite concerns regarding extensive cross-over between groups and the possibility of treatment confounders which may inherently arise in pragmatic trials, the group was convinced that this study was effective in adding to the growing body of evidence against the use of synthetic colloids in sepsis.  By: Dr. Magdalena Kisilewicz (Presented September 2013)