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Showing posts from May, 2015

When do supervising physicians decide to entrust residents with unsupervised tasks?

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Methodology: 3/5 Usefulness: 3/5
Sterkenburg A, Barach P, Kalkman C, Gielen M, ten Cate O. Acad Med 2010;85(9):1408–17.
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In this mixed methods study, the authors employ both quantitative (surveys) and qualitative (interviews) approaches to determine when supervising anesthesiologists decide to entrust their residents with unsupervised tasks.  Survey results demonstrated variable expectations by faculty with regards to when residents should be entrusted with unsupervised tasks.  Further, residents reported a higher self-efficacy and also a higher level of actual performance/responsibility than mean faculty expectations.  In the qualitative portion of this study, factors influencing entrustment decisions fit into four main themes: trainee, supervisors, circumstances, and task.  JC attendees felt that while this study was limited by small sample size it should be regarded as a foundational paper in the Entrustable Professional Activities (EPAs) literature and that this type of s…
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A randomized trial of intraarterial treatment for acute ischemic stroke

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Methodology Score: 4/5                    Usefulness Score:  3/5
Berkhemer OA et al for the MR CLEAN Investigators. N Engl J Med. 2015 Jan;372(1):11-20.
Full Article
This pragmatic, multicentre, block-randomized RCT in the Netherlands found that intraarterial treatment within 6 h + usual care was superior to usual treatment (generally IV thrombolytics) alone for patients with proximal anterior circulation clots (Primary outcome OR 1.67).  The JC attendees agreed that although lacking some descriptive information in regards to how patients were exactly treated both in hospital as well as pre-hospital, this is a practice-changing article for the neurology world, which will undoubtedly affect our emergency practice in the near future. By: Dr. Noam Katz (Presented January 2015)

Epi lesson: Explanatory versus Pragmatic Clinical Trials Trials of healthcare interventions are often described as either explanatory or pragmatic. Explanatory trials generally measure efficacy - the benefit a treatment…
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Entrustable Professional Activities: Making Sense of the Emergency Medicine Milestones.

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Methodology: n/a (concept paper) Usefulness: 4/5
Beeson MS, Warrington S, Bradford-Saffles A, Hart D.  J Emerg Med 2014;47(4):441–52.


Abstract Link
In this concept paper, the authors propose that Entrustable Professional Activities (EPAs) can be broken down into component knowledge, skills and attitudes that are mapped to competency milestones and proficiency levels. They argue that EPAs are units of practice that faculty and residents can more easily understand and therefore assess. While the authors describe the spectrum of emergency medicine EPAs based on clinical presentation (e.g. altered mental status), JC attendees felt these EPAs should instead be based on distinct aspects of emergency care practice (e.g. critical care resuscitation, transfer of care, patient discharge). By: Dr. Warren Cheung (Presented May 2015)
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Comparison of the efficacy and safety of new oral anticoagulants with warfarin in patients with atrial fibrillation: a meta-analysis of randomised trials.

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Methodology Score: 3.5/5        Usefulness Score: 4/5
Ruff CT, et al. Lancet. 2014 Mar 15;383(9921):955-62.
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This systematic review comparing NOACs to warfarin for patients with atrial fibrillation found that NOACs were marginally safer and more effective than warfarin.  JC attendees felt that the efficacy outcome may have been falsely inflated because hemorrhagic stroke was included in both the efficacy and safety outcomes, and they also had concerns that all 4 trials examined were funded by pharmaceutical companies.  Despite this, these results could be applied to ED patients requiring de novo anticoagulation for their new-onset atrial fibrillation, especially given the difficulties in starting a patient on warfarin from the ED. By:Dr. Ashley Krywenky

Epi Lesson: PRISMA statement
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Ultrasonography versus Computed Tomography for Suspected Nephrolithiasis

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Landmark Series
Methodology Score: 4/5           Usefulness Score: 4/5
Smith-Bindman R, et al. N Engl J Med.2014 Sep 18;371(12):1100-10.
Full Article
This multicentre randomized trial of over 2700 patients with suspected nephrolithiasis compared an ultrasound first approach, either point-of-care (POCUS) or official radiology ultrasound, with a CT first approach for the diagnostic workup of flank pain. Although many patients in the ultrasound first group subsequently underwent CT scans, they were still exposed to significantly less ionizing radiation over a 6 month period. JC attendees also remarked that in in carefully selected patients with suspected nephrolithiasis, the rate of significant adverse events was extremely low in all groups – well under 1%.  By:Dr. Sebastian Dewhirst

Epi Lesson: Selection Bias in RCTs
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Clinical and safety outcomes associated with treatment of acute venous thromboembolism: a systematic review and meta-analysis

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Methodology Score: 4/5          Usefulness Score: 3.5/5
 Castellucci LA, et al.JAMA.2014 Sep 17;312(11):1122-35.
Full Article
This network meta-analysis comparing the efficacy and safety outcomes associated with 8 anticoagulation options (unfractionated heparin, LMWH or fondaparinux in combination with Vitamin K, LMWH with dabigatran or edoxaban, rivaroxiban, apixaban and LMWH alone) found no statistically significant differences; however, a suggestion that UFH-Vit K is the least effective strategy and rivaroxiban and apixaban may be associated with the lowest bleeding risk.  Overall, the group felt that the methodology was excellent and while some JC attendees are changing their practice, there was not overall consensus that this was yet indicated. By:Dr. Amanda Collier (Presented December 2014)

Epi Lesson: Network Meta-analysis
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