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Showing posts from October, 2016

Immediate total-body CT scanning versus conventional imaging and selective CT scanning in patients with severe trauma (REACT-2): a randomised controlled trial

Journal Club SummaryMethodology Score: 3/5
Usefulness Score: 2.5/5

Seirink JC et al. Lancet. 2016 Aug 13;388(10045):673-83. Abstract Link
This is a multicenter randomized control trial of over a thousand trauma patients at five Level 1 trauma centres in western Europe that found no difference in mortality between an early whole-body CT “panscan” to a standard workup that include xrays, FAST and selective CT scanning. Although this was a good attempt at providing much-needed level 1b evidence, the group felt that the subjective inclusion criteria and high rate of crossover clouded the ability to apply the results in a meaningful way. By: Dr. Rajiv Thavanathan

Epi lessonDescribing the Strength of Study Results Using “Levels of Evidence”Different methods of classifying levels of evidence have been proposed, most of them relying on the study design, their precision, or their endpoints (e.g. survival with good neurological outcome). The Oxford classification is one commonly…

Ah, that feels better! The Use of Nerve Blocks in the ED.

The ability to administer peripheral nerve blocks in the ED has the potential to provide fast and direct analgesia with less systemic side effects compared to parenteral medications. When administered by an experienced provider, studies have shown that peripheral nerve blocks can provide reliable and prolonged analgesia. There is also evidence that nerve blocks can decrease overall length of stay in the emergency department for specific procedures. While there are various peripheral nerve blocks that are appropriate in the ED setting, there are three in particular that are further supported by evidence:

Interscalene BlockRegional Nerve Blocks of the HipNerve Blocks for Headache
The clinical use of these blocks is discussed here. Specific details and step by step instructions are described in the reference articles below.

The Interscalene Block The main indications for this block include:
Instant analgesia for upper-extremity fractures (proximal humerus, midshaft humerus)Exploration, debri…

Delivering safe and effective analgesia for management of renal colic in the emergency department: a double-blind, multi group, randomized control trial

Journal Club SummaryMethodology Score: 4.5/5                 Usefulness Score:  3.5/5
Pathan SA, et al. Lancet.2016 May 14;387(10032):1999-2007  Abstract Link Editorial:Non-steroidalanti-inflammatory drugs for renal colic Knoedler JJ, et al. Lancet.2016 May 14;387(10032):1971-2.
This three-arm RCT of 1,645 renal colic patients in Qatar found that IM diclofenac was slightly more effective than IV morphine or IV paracetamol, with fewer adverse effects.The utility of the study is limited by use of drugs not available in North America, and the lack of an NSAID + opioid treatment arm; while not currently practice-changing for us, this article generates critical thought on the use of opioids during a time where narcotic abuse is increasingly problematic. By: Dr. Thara Kumar
Epi lessonUse of Continuous Data as Primary Outcome
Beware of studies that compare the effectiveness of interventions using continuous data outcomes, such as pain scales (1-100), oxygen saturation values, and minutes to pain re…

Ticagrelor versus Aspirin in Acute Stroke or Transient Ischemic Attack

Journal Club SummaryMethodology Score: 5/5                    Usefulness Score:  3.5/5
Johnston SC, et al. N Engl J Med.2016Jul 7;375(1):35-43. Full Article
This large international double-blind double-dummy RCT across 33 countries and including 13,199 patients did not show a benefit of ticagrelor over ASA in reducing composite outcome of stroke, MI, or death at 90 days after a minor stroke or high-risk TIA.With respect to antiplatelet monotherapy for stroke secondary prevention, the findings of this rigorous study diminish the potential role of ticagrelor. By: Dr. Miguel Cortel

Epi lessonNumberNeeded to Treat (NNT) The NNT concept was created By: Canadian Clinical Epidemiologist Dr Andreas Laupacis in 1988 to quantify the benefit of a new intervention.NNT is the average number of patients who need to be treated to prevent one additional bad outcome (e.g. the number of patients that need to be treated for one to benefit compared with a control in a clinical trial). It is easily calculated…