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Showing posts from March, 2014

Targeted temperature management at 33°C versus 36°C after cardiac arrest

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Landmark Article Series Nielsen N, et al.; TTM Trial Investigators. N Engl J Med. 2013 Dec 5;369(23):2197-206.
Methodology Score: 5/5                             Usefulness Score: 5/5
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In this multicenter, international RCT of 950 unconscious adults after out-of-hospital cardiac arrest, hypothermia at a targeted temperature of 33°C did not confer a mortality or neurologic function benefit as compared with a targeted temperature at 36°C.  The group uniformly agreed that methodologically, this study was exceptionally-well run, making it a landmark, practice-changing study for Emergentologists & Intensivists everywhere.  By: Dr. Aseem Bishnoi (Presented Dec 2013)

Epi lesson: Hazard Ratio (HR) The hazard ratio is akin to relative risk but is used for survival analyses such as Cox proportional hazards regression. It is most often used to describe the outcome of therapeutic trials where the question is, to what extent can treatment shorten the duration of an illness. The hazard ratio…
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Clopridogrel with Aspirin in Acute Minor Stroke or Transient Ischemic Attack

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Methodology Score: 4 /5                 Usefulness Score: 3.5/5
Wang Y, Johnston SC, Wang Y. N Engl J Med. 2013 Oct 3;369(14):1376-7.
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This multicenter randomized-control trial of 5,100 patients with TIA/minor stroke treated within 24 hours found clopidogrel and aspirin was superior to aspirin alone for secondary prevention of stroke within 90 days (ARR 3.5%, HR 0.68, 95% CI 0.57 - 0.81,p <0.001), without increasing the risk of significant hemorrhage (0.3% in both groups.) JC attendees appreciated the strong methodology, with successful and appropriately stratified randomization and an acceptable loss to follow-up.  However, the generalizability to our patient population was questioned as other secondary stroke prevention practices differ in China.  By: Dr. Layli Sanaee (Presented January 2014)

Epi lesson: Verifying the power of an RCT
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Efficacy and safety of the novel oral anticoagulants in atrial fibrillation: a systematic review and meta-analysis of the literature

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Methodology Score: 4.5/5              Usefulness Score: 3/5
Dentali F, Riva N, Crowther M, Turpie AG, Lip GY, Ageno W. Circulation. 2012 Nov 13;126(20):2381-91.
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This was a systematic review and meta-analysis of 12 phase II/III RCTs which found that using NOACs (dabigatran, rivaroxaban, apixaban, edoxaban) over warfarin in patients with AF reduced total (ARR 0.4%) and cardiovascular mortality; stroke/systemic embolism, with a trend towards reduced bleeding. The analysis was dominated by 3 main trials and JC attendees noted that some authors of this review were employed by pharmaceutical companies. Despite the high quality methods of this meta-analysis, JC attendees were split over prescribing NOACs in the ED given the lack of reversal agent/antidote and potential complications of major bleeding.  By: Dr. Gauri Ghate (Presented January 2014)

Epi lesson: PRISMA Statement for Reporting Systematic Reviews
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A new and rapid method for epistaxis treatment using injectable form of tranexamic acid topically: a randomized controlled trial

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Methodology Score: 2/5                 Usefulness Score: 3.5/5
Zahed R, Moharamzadeh P, Alizadeharasi S, Ghasemi A, Saeedi M.Am J Emerg Med. 2013 Sep;31(9):1389-92
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This single centre, ED based, parallel group randomized control trial found that the topical application of an injectable form of tranexamic acid (TXA) was better than anterior nasal packing (ANP) for halting bleeding within the first 10 minutes (ARR=40%, P=<0.001) and discharging the patient from the department within the first 2 hours (ARR=89%,P=<0.001). The DEM journal club identified several errors in the paper which compromised the validity of the results; however, the overall cost effectiveness (500mg TXA at The Ottawa Hospital = $5.90) and the potential for significantly decreasing patient discomfort made this low-risk intervention very appealing to attendees.  By:Dr. Nicholas Costain (Presented January 2014)

Epi lesson: p values in baseline characteristic tables

Whether or not to present p values in Tab…
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The benefits of steroids versus steroids plus antivirals for treatment of Bell's palsy: a meta-analysis

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Methodology Score: 3.5/5               Usefulness Score: 3.5/5 Quant EC, Jeste SS, Muni RH, Cape AV, Bhussar MK, Peleg AY. BMJ. 2009 Sep 7;339:b3354. doi: 10.1136/bmj.b3354.
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This meta-analysis of randomized controlled trials comparing the use of steroids alone vs steroids and antivirals in the treatment of Bell’s palsy found that there was no benefit to the use of antivirals, with an odds ratio for combined treatment of 1.50 (95% CI 0.83-2.69).JC attendees found the study very methodologically sound save for the abstraction error that led to significant alteration in final results (corrected OR with per protocol data of 1.72 (95% CI 1.02 – 2.88)).Taking the current literature into account attendees felt that this supports the idea that not all patients may benefit from antivirals but they should likely be offered to severely affected patients or very early presentations.  By: Dr. Valerie Charbonneau

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