EMOttawa - Emergency Medicine Ottawa

Journal Club Summary Methodology Score:4/5 Usefulness Score:4/5 Stanley AJ, et al. BMJ. 2017 Jan 4;356:i6432. Full Article This multicentre, multinational study assessed the ability of five upper gastrointestinal bleeding scores to predict outcomes including death, re-bleeding, need for endoscopy, transfusion, surgery or interventional radiology, and length of hospital stay, finding that the Glasgow Blatchford score is best at predicting the composite outcome of intervention or death, although AIMS65 was best at predicting mortality. While applying the scores as recommended may result in missing a small number of significant outcomes, they are easy to apply and can help expedite disposition planning, whether outpatient management or hospital-based intervention. By: Dr. Daniel James
Epi lessonComposite OutcomesIt is not unusual for studies to select a composite outcome as their primary outcome measure. The necessity to do so is often justified by the rare occurrence of the primary outcome of t…

Journal Club SummaryMethodology Score: 4/5                    Usefulness Score: 3.5/5
Hinson JS, et al. Ann Emerg Med. 2017 Jan 19 [Epub ahead of print] Full Article

SummaryMethodology Score: 4/5
Usefulness Score: 3.5/5

Patel BK, et al. JAMA. 2016 Jun 14;315(22):2435-41
Full Article

Editorial: Unmasking a Role for Noninvasive Ventilation in Early Acute Respiratory Distress Syndrome. Beitler JR, et al. JAMA. 2016 Jun 14;315(22):2401-3.

This single-centre, non-blinded RCT of ICU ARDS patients, found that NIV delivered by a novel helmet, as compared to a standard NIV facemask, reduced intubations (18.2% vs. 61.5%; P <0.001) and hospital mortality (27.3% vs. 48.7%; P= 0.04). Despite its few methodological flaws, this study supports the existing literature on the advantage of oxygen delivered via helmet over facemask in avoiding intubation in ARDS, and future studies should focus on its impact in heart failure or hypercapneic respiratory failure.
By: Dr. Shannon Fernando 
Epi lesson:
Interim Analyses and Stopping Rules
In clinical trials, an interim analysis is one that is conducted before data collection has been completed to determin…

Journal Club SummaryMethodology Score: 4/5                    Usefulness Score: 2/5
Miller LG, et al. N Engl J Med.2015Mar 19;372(12):1093-103. Full Article

Journal Club Summary Methodology Score:4.5/5 Usefulness Score:4/5
Thiruganasambandamoorthy V, et al. CMAJ. 2016 Sep 6;188(12):E289-98 Full Article
This large multicenter prospective ED syncope study derived a methodologically robust risk tool for prediction of 30-day serious adverse events after ED disposition. This risk score will aid in ED management of patients: those at higher-risk require further management (thorough assessment and investigations including outpatient cardiac monitoring); and once validated the tool can aid in identification and quick disposition of low-risk patients.   By: Dr. Robert Ohle
(Full Disclosure: Dr. Thiruganasambandanmoorthy is an EMOttawa staff and was the lead author of the study. For a full explanation of the Canadian Syncope Risk Scale from the author see this post) 
Epi lessonApproach to Decision Rule Development In this era of clinical decision tools being developed for almost anything, we need to think will a clinical decision tool be helpful and how to…

Journal Club SummaryMethodology Score: 3.5/5               Usefulness Score:  2/5
Prandoni P, et al. N Engl J Med. 2016 Oct 20;375(16):1524-1531.
Full Article
This cross-sectional multi-center study of Italian patients admitted after an ED presentation for syncope found a 17.1% PE rate among admitted patients and 3.8% among all-comers to the ED. These results are in stark contrast to current perceptions and measured data surrounding prevalence and outcomes with syncope and PE. The group felt the differences are due in large part to spectrum bias and in part due to over-diagnosis and incidental findings. Studies in populations similar to ours would be required to change current practice. 
By: Dr. Michael Ho
Epi lessonBy: Dr. Venkatesh Thiruganasambandamoorthy Spectrum Bias: For clinicians the probability and the seriousness of underlying condition(s) previously reported dictates how aggressively they investigate to identify the serious condition. Seriousness depends both on the condition (e.g…

Journal Club SummaryMethodology Score: 4/5                    Usefulness Score:  2/5
Zemek R, et al. JAMA. 2016 Mar 8;315(10):1014-25. Full Article
Editorial: Identifying Children and Adolescents at Risk for Persistent Postconcussion Symptoms. BabcockL, et al. JAMA.2016Mar 8;315(10):987-8.
This was a prospective multicenter cohort study of pediatric patients with acute concussion that derived and validated a clinical decision rule with modest discrimination to assess risk of persistent postconcussion symptoms at 28 days.  The group felt that while very methodologically sound it would have limited role in the ED given the lack of validated treatment options for concussion but it may have a role to develop a high risk group to target further research. By: Dr. Rory Connolly

Epi lessonWhat is Collinearity? Why does it Matter? How do you Measure it?Collinearity means that two of the predictors entered in a regression analysis model correlate with each other (they measure almost the same thing, e.g…

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…