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Showing posts from January, 2015

Does this patient with shoulder pain have rotator cuff disease?: The Rational Clinical Examination systematic review

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Methodology Score: 3.5/5                 Usefulness Score:  2.5/5
Hermans J, et al. JAMA. 2013 Aug 28;310(8):837-47.
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This systematic review of studies comparing clinical tests for rotator cuff disease with a diagnostic reference standard of MRI or U/S found that positive tests of internal rotation lag ((+)LR 5.6, 95% CI 2.6 – 12), external rotation lag (LR 7.2, 95% CI 1.7 – 31), and the painful arc ((+)LR 3.7, 95% CI 1.9 - 7.0) have the highest positive likelihood ratios for rotator cuff disease. JC attendees agreed that the question is useful, but that the studies included in this systematic review lacked reproducibility and generalizability to an emergency department population, and that their large 95% CI’s preclude the utility of these results in changing our daily practice.                                                          By: Dr. Laura Francis

Epi lesson: Verification Bias When critically appraising a study evaluating a diagnostic test, it is important to examine th…
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Mechanical Chest Compressions and Simultaneous Defibrillation vs Conventional Cardiopulmonary Resuscitation in Out-of-Hospital Cardiac Arrest The LINC Randomized Trial

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Methodology Score:    4/5                    Usefulness Score: 2.5/5
Rubertsson S, Lindgren E, Smekal D, Östlund O, Silfverstolpe J, Lichtveld RA, Boomars R, Ahlstedt B, Skoog G, Kastberg R, Halliwell D, Box M, Herlitz J, Karlsten R. JAMA. 2014 Jan 1;311(1):53-61.
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This large multi-centre randomized controlled trial compared the survival of patients with out of hospital cardiac arrest treated with a standard manual CPR algorithm vs. a mechanical CPR algorithm using an automatic CPR device; no difference is survival was noted. Given the lack of significant difference in the outcomes and the significant cost of the mechanical CPR devices the general consensus was that there would not be a benefit to implementing a mechanical CPR strategy in most circumstances. By: Dr. Sameer Vakani (Presented Sept 2014)

Epi lesson:Minimal Clinically Important Difference in Clinical Trials
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Ondansetron and the Risk of Cardiac Arrhythmias: A Systematic Review and Postmarketing Analysis

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Methodology Score:    3.5/5                 Usefulness Score:  2/5
Freedman SB, Uleryk E, Rumantir M, Finkelstein Y. Ann Emerg Med. 2014 Jul;64(1):19-25.e6.
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This retrospective review of adverse drug reaction (ADR) registries and case reports found that there were no reported events of arrhythmia after a single PO dose of ondansetron but found 59 cases of arrhythmias within 24hours of administration of parenteral ondansetron and chronic PO use.  The authors found there was a weak association between ondansetron administration and the arrhythmias reported.  The group agreed that the QT prolongation effects of ondansetron are likely clinically underappreciated and that it should be avoided in high-risk groups, as there are anti-emetics without QT prolongation as a side effect. By: Dr. Shawn Mondoux (Presented Sept 2014)

Epi lesson:Review of Grey Literature in Systematic Reviews
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Thrombolysis for Pulmonary Embolism and Risk of All-Cause Mortality, Major Bleeding, and Intracranial Hemorrhage: A meta-analysis

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Methodology Score:    4.5/5                 Usefulness Score:  3/5
Chatterjee S, Chakraborty A, Weinberg I, Kadakia M, Wilensky RL, Sardar P, Kumbhani DJ, Mukherjee D, Jaff MR, Giri J. JAMA. 2014 Jun 18;311(23):2414-21.
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This methodologically-sound meta-analysis found that among patients presenting with both massive and sub-massive pulmonary embolism, thrombolysis was associated with decreased risk of all cause mortality compared with anticoagulation (OR, 0.53; 95% CI, 0.32-0.88; NNT = 59) and an increased risk of major bleeding (OR, 2.73; 95% CI, 1.91-3.9; NNH = 18).  The group felt the in sub-massive PE, the mortality benefit of thrombolysis most clearly outweighed the risk of bleeding in patients under the age of 65 (NNT = 51, P = 0.09 vs. NNH = 176, P = 0.89) and, in consultation with thrombosis, we would consider thrombolysis for this patient population. By: Dr. Magdalena Kisilewicz (Presented Sept 2014)

Epi lesson: Cochrane Collaboration Tool for Assessing Risk of Bias in In…
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