pca 13-14
TRANSCRIPT
Top 10 (Potentially)
Practice Changing
Articles from the EM
Literature
10
linear lac<8 cmtrunk or extremities
-facial lac-non-linear-over area of tension-dirty or > 12 h-steroids or sig PMH
X
3 mo: cosmetic outcome
vicryln=55
prolinen=58
Silva S, Wyer P. The roadmap tutorial. 2010.
xx
x
?
9
simple corneal abrasion
>36 hours after injuryprior eye surgery or cataractcontact lens wearbilateral eye injuryinfectionunable to follow up within 48 h
X
safety and healing
salinen=61
tetracainen=61
Silva S, Wyer P. The roadmap tutorial. 2010.
x x
61=63 61=63
Tetracaine Saline
fluorescein uptake 23.9% 21.3% p=0.761
48h: persistent sx 21.7% 21.3% p=0.957
1 wk: persistent sx 2.2% 8.5% p=0.176
1 mo: complications 0% 0%
24 h: pain ∆0.44mm p=0.259
48 h: pain ∆0.53mm p=0.149
?
Dr. Keiji Hayashi“We have some questions on the conclusion in your Oseltamivir review, especially about the prevention of complications... we have found that this conclusion is based on [another] review (Kaiser 2003) and not on your own data analysis. The authors of the review were four employees of F. Hoffman-La Roche Ltd... Kaiser’s review included 10 RCTs; [only] two RCTs (Nicholson 2000 and Treanor 2003) were published... in the peer-reviewed medical journal (JAMA and Lancet)... the lower respiratory tract complication rates of these articles [showed] no significant difference between Oseltamivir and placebo, and their ORs were 1.81. But the OR of the other 8 [unpublished] RCTs were 4.37...”
8
Beginning EndMiddle
•explicit & appropriate eligibility criteria?
• biased selection and reporting of studies?
•what is the overall quality of the evidence?
• primary studies of high methodologic quality?
• were results similar from study to study?
•were all patient-important outcomes considered?
•assessments of reviews reproducible?
•did results rely heavily on data from one trial?
•are benefits worth costs and risks?
XX
Silva S, Wyer P. The roadmap tutorial. 2010.
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7
ED discharge diagnosis: “allergic reaction”
< 17 years oldDx: “asthma with allergic reaction”left without being seenpre-existing non-allergic angioedema
7-day: biphasic reaction
anaphylaxisn=496
X
allergyn=2,323
Silva S, Wyer P. The roadmap tutorial. 2010.
anaphylaxisn=496
allergyn=2,323
index visitn=2
(0.07-1.6%)
index visitn=0
(0-0.21%)
2nd visitn=0
(0-0.96%)
2nd visitn=3
(0.03-0.41%)
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6
ED physician-confirmed cellulitis
admittedrecent abx treatment for cellulitiscognitive impairmentilliterate
X
covariates:PMH, abx, illicits, VS, exam, ED rx
2-week: treatment failure
Beginning EndMiddle• are patients, variables and outcomes clearly defined?
• is the spectrum of patients to whom the rule will be applied well-represented?
• was the rule validated in a different group of patients?
• were predictors and outcomes evaluated in a blinded fashion?
• were predictors and outcomes evaluated in the entire sample and in the same way?
• were the statistical methods clearly described?
Silva S, Wyer P. The roadmap tutorial. 2010.
x x
20%
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5
CT “flank pain protocol”
lack of flank painhx traumainfection: fever, urine leuksmalignancyrenal diseaseprior urologic procedure
X
covariates:PMH, VS, exam, ED rx
dx ureteral stone
Beginning EndMiddle• are patients, variables and outcomes clearly defined?
• is the spectrum of patients to whom the rule will be applied well-represented?
• was the rule validated in a different group of patients?
• were predictors and outcomes evaluated in a blinded fashion?
• were predictors and outcomes evaluated in the entire sample and in the same way?
• were the statistical methods clearly described?
Silva S, Wyer P. The roadmap tutorial. 2010.
x
Low-prob: 0-5
Mod-prob: 6-9
High-prob: 10-13
1.6%High-prob group
10% of High-prob group
?
4
ED pts with clinical suspicion of PEemploying new diagnostic strategy(if age>50: cutoff = age*10)
ACcontrast allergyCRIlife expectancy < 3 mospregnantinaccessible for follow-up
X
3-months: VTE & death - all comers
3-months: VTE & death - 500<d-dimer<age*10
Silva S, Wyer P. The roadmap tutorial. 2010.
0.3% (0.1-1.7)0.1% (0-0.7)
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3
imaging-confirmed CVA<48 h onsetSBP 140-220
- BP >220/140-MI, CHF, AF, dissection-cerebrovascular stenosis-deep coma
X
14 d: death and major disability
BP lowering by10-25% in 24 h
n=2,038
no BP treatmentn=2,033
MRS
Silva S, Wyer P. The roadmap tutorial. 2010.
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2
in press
N/VED attending recommended IV meds
-unstable -chemo-pregnant -vertigo-movement disorder
X
30 min: ∆VAS nausea severity rating
placebon=83
reglann=88
zofrann=87
Silva S, Wyer P. The roadmap tutorial. 2010.
x
?
controversy?
“one concern I have is thatthis hypothesis has been accepted almost without debate by so many people”
“the new therapy costs about $1,100 more per patient”
“Pittsburgh Pirates... ”
“thinly-veiled academic lynching”
1
sepsis suspected 2+ criteria for SIRSrefractory hypotension or lactate ≥4
-primary neuro, CV or pulm dx -OD, burn or trauma-need for immediate surgery-CD4<50
X
60 d: in-hospital mortality
usual caren=458
EGTn=445
protocol-based standard tx
n=448
Silva S, Wyer P. The roadmap tutorial. 2010.
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