Providence

 

Papers

warning: Creating default object from empty value in /var/www/vhosts/sphemerg.ca/httpdocs/modules/taxonomy/taxonomy.pages.inc on line 33.

Weekly Reading List

The Weekly Reading List

... and we're back...

So, 2 months off for Summer, St Paul's Emergency Medicine Update, the birth of my second child.  Things have been quiet here, but not on the Webs.

At ICEM 2012, a group of EM and SoMe (Social Media) thought leaders put their heads together over a pint of Guiness (it was Dublin after all) to come up with the next step in Medical Education in the Wild West we call the Internet.  Thus was born FOAM (Free Open Access Meducation). This was 'shortened' to FOAMed. The goal was/is to provide a loose structure and enhanced usability to the array of EMCC (Emergency Medicine and Critical Care) blogs, podcasts, tools, and resources available on the Web, and to harness that bounty to improve Medical Education. Don't take my word for it, check out the originators:

The first 2 big tools to help harness all this are:

emgoogle.com - a Google Custom Search Engine (created by yours truly) that ONLY searches EMCC blogs, podcasts, tools and Journals. This is a good first filter, and if you don't find what you need, then you can resort to the full Google.

foamem.com - a realtime RSS feed of all the known EMCC blogs and podcasts.  You can visit the site to see the latest, or subscribe to their integrated, single stream RSS feed.

So, welcome to #FOAMed !

Okay, but what else happened?  Here is a smattering of other good stuff from the web:

Ultrasound for Subclavian Lines - you can do that?  Yes you can!

Dr Ves at CasesBlog points us to the new Guidelines for Management of Acute Bacterial Sinusitis (it's not sexy but it is important)

Does this overdose need dialysis? Review of Extracorporeal Removal Techniques for the Poisoned Patient

Urine Drug Screening - Useful? Part One focusses on Benzos, Part Two on Opiates.

Have you been given a Field Note by a FM resident? Want to know What's up?

Is that cut 'too old' to close? Are you sure? (Journal Link)

ENLS -Emergency Neurological Life Support (What to do in the first critical hour of a neurological emergency). This is a new 'Advanced Life Support' course, but the Protocols and the background info are FREE!  Yay FOAMed.

Erowid - more than anyone needs to know about Psychoactive substances... from a slightly different point of view.

Are you scared of CROCODILEs? A new approach to Pt Safety with Learners in the driver's seat.

Finally, this is just cool!


Enjoy the weekend.

Virtual Journal Club - Atrial Fibrillation Outcomes

Virtual Journal Club

Our Research Super Stars are at it again! Dr Scheuermeyer and the team (including Drs Grafstein, Stenstrom, Pourvali, and Christensen) have just published "Thirty-Day and 1-Year Outcomes of Emergency Department Patients With Atrial Fibrillation and No Acute Underlying Medical Cause" in the Annals of Emergency Medicine.


927 of our patients were studied, with a combined death (5 pts) and stroke (2 pts) rate of 0.8% (CI 0.3%-1.6%) at 30 days.


Read the paper, login to the site, and leave your thoughts and comments.


The article can be found on:

 

PubMed PMID:22738681 (use this if you are at work or use UBC myVPN from home)

 

The Annals Website (use this if you have direct access to the journal online)

 


 

 

 

The Issue with the International Stroke Trial 3

When I read this blog on my phone on a clinical shift (http://smartem.org/content/delusions-benefit-international-stroke-trial), I felt I needed to respond earlier rather than later.  It is an interesting editorial.  I hope to respond by giving an unbiased, objective comment and show that I'm not completely delusional myself.  Again, my disclaimer is that I am not industry funded, nor have ever been (by tPA makers) and I don't get paid more to sell more tPA or have more tPA given.

To be honest, when this trial was developed, most of the sites in Canada didn't sign on because they thought it was a poorly designed trial and likely to fail from the start.  The only Canadian site is Halifax.  In addition, no one in the States signed on.  Same reason.

The problem with the trial is that it doesn't answer any questions - that tPA works or that it doesn't - because it is not well designed.  So, over 11 years, in multiple countries, over 3000 patients, it doesn't add anything to the literature, nor provide any direction on what to do.  It was non-industry funded despite some investigators having multiple conflicts of interest, individually.

The reasons it is useless:
1. Enrolment was supposed to be 6000 to detect a significant difference in primary outcome.  Enrolment was slow (due to my next point), so they settled on 3000.  Obviously, no power to detect a difference.  Regardless of the lack of power, the fact that no difference was shown in the primary outcome reinforces that an effect size was probably small, regardless.  
2. The major problem with this trial is the fact that it was designed using an 'uncertainty principle.'  In short, this meant that the treating (enrolling) physician would enrol a patient in the trial ONLY IF there was NO CLEAR INDICATION for thrombolysis OR if there was A CLEAR INDICATION NOT to thrombolyse (i.e. a clear contraindication).  Again, this means that those patients who were deemed to be clear candidates for thrombolysis were not enrolled.  They were excluded and were treated "...in accordance with local guidelines."  So, this is the reason why the enrolment dropped off.  Physicians were enrolling less and less patients in the trial because they felt there was an indication for thombolysis.  So, IST-3 contained equivocal patients - ones who had relative contraindications, or no clear indication to thrombolyse (maybe a hail Mary?).  And they didn't even give a description of the patients who were screened and excluded.
3. Unblinded and open?  What the heck?  No comment on this stupidity.

So now, be prepared for the pundits, 'experts', heretical prophets and industry puppets to now editorialize, argue, debate, and rant.  This is an unfortunate trial and an unfortunate situation for the Lancet.  I think they just felt bad for the IST-3 group and gave them a freebie.  This provides no direction for the anti-tPA group and no direction for the pro-tPA group.  What it does say, is that in patients who are equivocal candidates for thrombolysis (i.e. not sure if they are clear candidates or not, based on NINDS and ECASS III criteria), that thrombolysis shows no clear benefit.  And, due to the issue with power of the trial, if there is a benefit in this group, the effect size is most likely very small.

Interestingly, a few months ago, the New England Journal published a 2B trial (efficacy trial) on TNK versus tPA in acute ischemic stroke, and found that very carefully selected patients (CT, CT angio showing clot, small 'core') do benefit from thrombolysis, with TNK much better (72% no disability versus 40% no disability at 90 days).  What this trial does show, is that thombolysis is actually very, very effective in selected patients (ones who are hypothesized to have a clear benefit) and that TNK is actually better than tPA - finally, a new kid in town that will drive more clinical trials.

So, in answer to what to do, I suggest the emergency community shows temperance and patience.  Continue to identify potential tPA candidates, as per NINDS, ECASS III criteria.  Recognize that thrombolysis for acute stroke has never been, is not, and and never will be the silver bullet for stroke care.  Preventing stroke is the answer (urgent TIA care and work up).  Anti-coagulating atrial fibrillation patients is the answer.  Stroke unit care is the answer.  Better rehabilitation and nursing care is the answer.  Better home and community support is the answer.

My plea is to not throw the baby out with the bathwater.  Thombolysis in acute stroke kills and hurts people, yes, and is extremely harmful if patients are not carefully selected.  However, thrombolysis is beneficial in selected patients (and not selected like the NINDS trial, which was very strict).  I completely disagree with the editors of the 'smartem' editorial that this is the death knell for thrombolysis in stroke.  My opinion is that this study provides no further direction on whether it works or not, and any debate and fall-out from this article is inconsequential, sadly.  I would be disheartened to start hearing and reading that we as emergency physicians should start actively opposing the identification of potential thrombolysable candidates.  That action would be as misguided as the stroke specialists who say that tPA works unequivocally in almost everyone and who have tPA rates of 30%.


Original Lancet Paper Here

IST-3 Website

More EM comment:

EMLitofNote

EMIreland

Ed. Note:  Dr Harris is a respected Emergency Physician and expert in Stroke and TIA, and is the Co-Chair of the Provincial Advisory Panel for Stroke Care. You can read more about his Stroke and TIA work here.

Virtual Journal Club - The Chest Pain Pathway Paper

Virtual Journal Club

Dr Scheuermeyer and the reasearch group have recently published the validation of our beloved Chest Pain Pathway, in the Annals of Emergency Medicine.

This paper has the potential to change practice in EDs around the world, though as Dr Scheuermeyer can attest, there is significant resistance to the ideas presented in the paper especially with our American colleagues.

Update:

This paper has already been integrated into some high profile medical sites, being referenced in the Medscape Acute Coronary Syndrome article; is featured in Journal Watch; and garners a review by Ryan Radecki of the excellent EM Lit of Note Blog (follow on the blog and on Twitter - highly recommended). NEW - A new review on the EM Ireland Blog (another great blog - Andy is also doing a great series on Anatomy for EM (iTunes Link).  Blog here and Twitter here)

The article can be found on:

PubMed PMID:22221842 (use this if you are at work or use UBC myVPN from home)

The Annals Website (use this if you have direct access to the journal online)



 

Virtual Journal Club - Early Repolarization or STEMI?

Virtual Journal Club

Dr Stephen Smith (University of Minnesota) is an Emergency Physician at Hennepin Medicial Centre.  He runs the most excellent Dr Smith's ECG Blog, a MUST READ Emergency Medicine Blog.

He and his colleagues have just published, in Annals of Emergency Medicine, an interesting article:

Electrocardiographic Differentiation of Early Repolarization From Subtle Anterior ST-Segment Elevation Myocardial Infarction

They have derived and validated a formula to aid in this often difficult situation.

Come on Cardiac & Research geeks, let us know what you think.

Syndicate content