Journal club: Updates in Management of Ischemic Stroke and ATACH-2

Dr. Howes opened up his lovely home to host journal club this month on October 5, 2016 – it was an evening of pizza, ice cream, and enlightening discussion. As usual, two articles were featured. The commentary below, written by Kristen, was staff reviewed by Dan.

Endovascular thrombectomy after large vessel ischaemic stroke: a meta-analysis of individual patient data from five randomized trails 

by Goyal et al. published in the Lancet 2016.

Dr. Keegan Selby presented the resident chosen article listed above, providing an excellent summary of the “biggest thing to ever happen to neurology” in the context of current practices. To quote Dr. Rob Brison directly, the authors used a “really cool” technique to combine raw patient data from five previous studies, MR CLEAN, ESCAPE, SWIFT PRIME, REVASCAT, and EXTEND IA trials. It is amazing to see the possibilities with research collaboration such as this! We were lucky to have a strong staff presence to help us understand the basics of the mixed methods modelling used. The study is not a traditional meta-analysis and avoids much of the bias because patient level data was used and combined, rather than data that had already been sorted through and grouped. Importantly, authors did account for between-trial variation and were able to provide a more powerful and reliable conclusion than each individual study alone with these statistical techniques. Interestingly, the National Institute of Research is hoping to make all raw data available online from authors who publish under their grants in the future. Just think of the possibilities!

evt

In the end, we agree with the authors’ conclusion – EVT seems like a great idea to reduce disability in patients with large vessel anterior circulation ischemic strokes if you live close enough to a center proficient in this technique in a system that can afford it. Here in Kingston, we are capable – what remains to be determined is whether this is something that is feasible and ethical for KGH.

[Extra tidbit: 5 patients have undergone EVT at KGH – it is currently available during business hours to the optimal candidates. Bottom line: discuss with the stroke team if you encounter a patient with a large anterior ischemic stroke in the ED.]

 

Intensive Blood-Pressure Lowering in Patients with Acute Cerebral Hemorrhage (ATACH-2) 

by Qureshi et al. published in NEJM 2016

Dr. Howes led the dialogue through the chosen staff article, ATACH-2 . The authors conducted a randomized, multicenter, open-label trial to examine the effects of intensive blood pressure control in acute cerebral hemorrhage, comparing a target of 110-140mmHg to 140-179mmHg using IV nicardipine – and stopped enrollment early due to futility after interim analysis. I won’t go into all of the details but we had rich discussion surrounding the standard treatment of acute cerebral hemorrhage at KGH, the generalizability of the data to our population, the generous enrollment criteria, the inadequate power of the study (keeping in mind it was stopped early), and the practical difficulty and reader uncertainty surrounding specifics of blood pressure control in this study. In the end, as the authors conclude, this will not change our current practice in the management of acute cerebral hemorrhage. A few take home points were emphasized that can be applied to any article:

  • Always look at the estimate of treatment effect – the authors used a very optimistic 10% difference in likelihood of death or disability at 3 months between their intervention and standard treatment to calculate the power needed at the outset of this study.
  • A superiority trial ≠ an equivalency trial ≠ an inferiority trial – refer to a previous post by Eve, Arrests and Ankles at Astors, for a refresher
  • Be alert to misleading conclusions – Dan used a personal anecdote of a indexspecial stuffed animal to remind us to avoid the “blue dog” false conclusion in our research and analyses; just because you don’t find blue dog in your search, does not mean that you can conclude for certain that blue dog is not in the house.

 

Journal Club: Sepsis and Syncope

Dr. Stephanie Sibley stepped up to the plate last-minute and saved the day to host our first journal club of the year on September 13! It turned out to be an excellent showing and invigorating discussion (from what I was able to see – unfortunately I missed most of the first article). Dr. Carly Hagel and Dr. Theresa Robertson led the discussion about the new sepsis guidelines, walking us through the latest publication, The third international consensus definitions for sepsis and septic shock (Sepsis-3). The authors used a variety of methods – database interrogation, systematic literature review, and Delphi consensus with expert critical care physicians to create new and improved definitions for sepsis, septic shock, and pathophysiology of the syndrome. The table below outlines their new and improved definitions.slide1SIRs is out and qSOFA is in…but is it useful for us?

The SOFA (sequential organ failure assessment) score is used in the ICU and is proposed by the task force as a means to clinically characterize a septic patient, not as a tool for management. The authors used database interrogation to identify a SOFA score of ≥2 as a predictor of increased mortality in patients with suspected infection. The quick bedside test that has been proposed to trigger rapid recognition and management in the ED is qSOFA…but it has not been validated outside of the ICU. [SIRS is now considered a tool to help clinicians to recognize infection in the first place, but does not represent a dysregulated response to such infection as occurs in sepsis (poor discriminant and concurrent validity).]

qsofa

Carly + Theresa’s conclusion:

The published conclusion states that the updated definitions and clinical criteria should clarify long used descriptors and facilitate earlier recognition and more timely management of patients with sepsis or at risk of developing it. This conclusion is not supported by the data they quote. The SOFA is a predictor of mortality and has not been validated outside of the ICU setting. Nor has the qSOFA. Neither will facilitate earlier recognition – rather may be able to predict mortality in ICU patients.

The article chosen outlined the changes, but in order to find the selection criteria used for inclusion/exclusion of the specific databases used to support their work you will have to read the following:

It will be interesting to see where this new guideline goes and what discussion follows in the critical care, emergency, and hospital inpatient communities.

Syncope

The staff article chosen is one that we are all familiar with after filling out those pink sheets in the ED, involving our very own Dr. Marco Sivilotti: Development of the Canadian Syncope Risk Score to predict serious adverse events after emergency department assessment of syncope. Dr. Sibley graciously hosted us in her amazing new place, sharing some statistical knowledge to give insight into the derivation process used to come up with this tool. The most important take away here for our practical purposes is that it is a derivation study. Before we put it to clinical use, it’s important to follow the next phase – validation. Once validated, this tool proposes to help the clinician to identify adult patients with syncope who are at risk of a serious adverse event within 30 days of disposition from the ED. Unlike most clinical tools that we are used to using, this one hopes to allow us to risk stratify patients who present with syncope who are considered both high and low risk by our clinical judgment. We had an interesting discussion as a group with the frustrations of syncope and what we thought about each of the factors included in the tool. Unfortunately he wasn’t able to attend, but feel free to probe Marco for more details – as usual he will have a wealth of information and opinions to share! For a users’ guide to clinical decision rules, see this JAMA article.

We eagerly await the next update on the Canadian Syncope Risk Score!

 

Journal Club: Asthma Exacerbations and high sensitivity troponins – is less really more?

Our last journal club of the year was held at Dr. Dagnone’s house in beautiful patio weather (sorry for the delay in posting), where we discussed dexamethasone versus prednisolone for pediatric asthma exacerbations as well as the implications of the new high sensitivity troponin assay.

A Randomized Trial of Single-Dose Dexamethasone Versus Multi-dose Prednisolone for Acute Exacerbations of Asthma in Children Who Attend the Emergency Department

by John J. Cronin et al. published recently in the Annals of Emergency Medicine Journal

Dr. Heather White and Dr. Nick Cornell lead the group through a critical look at the recent article in Annals of Emergency Medicine regarding optimal management of acute asthma exacerbations in children. This was an intention to treat, randomized, and open label non-inferiority study looking at single dose dexamethasone compared to 3 days of prednisolone for treatment of acute asthma exacerbations in children. The conclusion was that dexamethasone (0.3mg/kg) was found to be non-inferior to a 3 day course of prednisolone (1mg/kg/d) as measured by the mean PRAM score on day 4.

The discussion was rich and the consensus seemed to lean away from practice changing impact. Several concerns were raised with the study including the generalizability to our practice environment and the bias introduced with open label methodology. The study was done in Ireland using a 1mg/kg dose of prednisolone, which is typically dosed at 2mg/kg here up front in the ED followed by 1mg/kg/day at home. The PRAM score was felt to be a reasonable surrogate for asthma control and severity, but the exclusion criteria was extensive and we thought that the differences in PRAM would be difficult to pick up. In the end, for a child with mild-moderate asthma exacerbation who does not tolerate prednisolone, single dose oral dexamethasone is a reasonable choice!

forest plot

 

Derivation of a 2hr high-sensitivity troponin T algorithm for rapid rule-out of acute MI in ED chest pain patients

presented at CAEP 2016 by A McRae

The staff article this week was a very topical abstract presented at the 2016 CAEP conference by the University of Calgary’s Andy McRae. Dr. Colin Bell had a lot to add to Dr. Dagnone’s points after presenting a Grand Rounds on this topic earlier this year. Before going any further, the importance of knowing your own center was highlighted – at Kingston General Hospital, the lab is using the cTnI assay, which has increased sensitivity compared to the cTnT assay utilized in Calgary and the focus of the abstract.

The abstract described a study performed in Calgary to derive a 2-hr high sensitivity cTnT testing algorithm to rule out acute MI in ED chest pain patients. Their conclusion was that acute MI can be ruled out safely with a high sensitivity cTnT algorithm in 58.5% of chest pain patients within 2 hours of ED arrival. Apart from the obvious issue with a different assay, the logistics of the above mentioned time points in our ED, the definition of low risk chest pain and quantification of such, and the lower sensitivity of the algorithm for major adverse cardiac outcomes compared to acute MI made us all a little hesitant. The future sure looks promising, but we concluded that we’re yet ready for use of the 2-hr delta troponins across the board. It is probably okay for low risk chest pain patients, but the 6-hr test is definitely safer. Although there is lots more work to be done on this topic, the Calgary group has done a great job thus far and we’d like to congratulate them on the well deserved Grant Innes Research Award for top ranked CAEP abstracts this year in Quebec City!

Stop Colin or Damon next time you run into them to ask about their opinion – they have a wealth of information to share!

 

*as a useful side note, it came to light that a delta troponin (using our local cTnI assay) should only be considered different if it is >8

 

Journal Club: Qualitative Research and Double Sequential Defibrillation

In this week’s edition of journal club we covered a paper that, through qualitative methods, assessed emergency physicians’ thoughts on opiate guidelines. As a group we have been speaking a lot about opiates and so we have elected not to cover the article in-depth in this review. We spent most of the night discussing qualitative methods in general. Below are some take aways for the next time you pick up a qualitative paper!

A great resource for critical appraisal of qualitative research is this BMJ article.

Journal Club May 2016

To download a pdf version of this article click here.

The staff article this week was an article looking at double sequential defibrillation and you can access it here. Though a simple case series it provided quite enthusiastic discussion. Next time you run into Adam or Colin ask them about what they think!

Look forward to seeing you at the next Journal Club!

Journal Club: Arrests and Ankles at Astor’s

It was a smaller than normal showing at Journal Club at Jack Astor’s but the discussion was better than the nachos…and they were awesome. This week’s edition of Journal Club featured two articles. The commentary below, written by Eve, was staff reviewed by Tim!

Amiodarone, Lidocaine, or Placebo in Out-of-Hospital Cardiac Arrest

by Peter Kudenchuck et al. published recently in the New England Journal of Medicine. 

Kathleen and Hadi chose this new paper and led the critical appraisal. The discussion was unbelievably rich. Summarizing the complexity is really beyond the scope of this blog post but suffice it to say, we agreed that we will continue to use antiarrythmics in arrests. Instead of going through the paper, which is worth taking the time to do when you get the chance, I thought I would draw attention to one research principle that came up in discussion so that you can keep it in mind when reading the article yourself! I want to credit all the folks who were at journal club for highlighting this, and many other, important points. Collaborative intelligence, especially when Dan’s insights are included,  is pretty neat.

Trials are designed to demonstrate superiority, equivalence or non-inferiority. Each of these trial types require different designs, have different outcomes, use different statistical methods and allow different conclusions to be drawn. The article we discussed was designed as a superiority trial but the authors’ conclusions were stated in equivalency or “no difference” terms which is not a true representation of how the original question was approached. If you are interested in learning more about this difficult to grasp concept, I often find myself having to come back to this article explaining the idea (interestingly it was also published in NEJM).

Journal Club April 19

If you weren’t able to make it to journal club, and even if you did, I’d encourage you to chat about this paper over the next coming days and weeks, there’s lots of food for thought.

Radiographic-Negative Lateral Ankle Injuries in Children: Occult Growth Plate Fracture or Sprain?

by Boutis K. et al (including our very own Dr. Brison) published in JAMA Paediatrics in January 2016.

Erin and Tim chose to look at an article which challenges the dogma that “kids don’t sprain ankle ligaments they break ankle bones”. Again it is worth reading this article. When you do, you’ll find that the rate of Salter 1 injuries in kids with inversion injuries with normal plain radiographs is very low (~3%) and those kids do very well with simple management.

For the junior residents, in case you are like me and need a reminder of the Salter-Harris fracture classification check out this great radiopedia article.

Next time you are working with Dr. Brison, ask him about this paper and pick his brain about ankles in general. I can guarantee you will learn something!

 

Look forward to seeing you at the next JC. 

Journal Club: pediatric mycoplasma pneumonia

I haven’t been working in the department since October but that doesn’t mean I haven’t stopped thinking about emergency medicine! In fact, I recently completed my peds emerg rotation at CHEO. While there, I was asked to present at journal club. Stu was too…so apparently they can’t get enough of Queen’s awesomeness.  Since there were two of us, and we were presenting we thought it appropriate to update our own department with our satellite journal club! I was charged with the task of appraising a systematic review on the treatment of mycoplasma pneumonia in kids. You can read the paper here.

The moral of the story is that the evidence is not good on this topic. Remember, pediatric pneumonia should be treated with amoxicillin as first line therapy. For a refresher, take a look at the CPS Pneumonia Guidelines. The evidence is very poor quality for targeting mycoplasma pneumonia with macrolides (i.e. azithromycin/clarithromycin) but this may be a reasonable approach in kiddos not responding to our first line treatment. For more info on the study, check out the infographic below and drop any comments that you might have!

mycoplasma-pneumonia-journal-club

To download a pdf version of this study click here.

 

The Concept

I look forward to Thursdays. I love walking into Richardson and seeing familiar faces, ready to discuss topics related to the specialty that I adore. The ritual of Grand Rounds will never get old but this site might help it evolve!

The Issue

Senior residents put an extraordinary amount into preparing for Grand Rounds and Journal Club. Their reviews are thought-provoking, discussion-inciting and sometimes practice-changing for those who attend. Unfortunately, busy schedules, off-service rotations and clinical duties make it impossible for all members of the department to be there in real-time. Furthermore, we are usually discussing issues that would benefit from collaboration with our specialist counterparts but again, scheduling makes their physical presence challenging to coordinate. We’ve been wondering:

Can we extend the discussion beyond the walls of Richardson Theatre? Can we offer a place for asynchronous engagement in Grand Rounds and Journal Club? Can we find a way for junior residents to be more involved?

Offering a Solution

We believe that the answer to all of the above questions is “Yes!”. Posts in the Journal Club and Grand Rounds sections will highlight content and the Our People posts will highlight the awesome folks that make up the QEmerg crew. These posts are not meant to replace attendance because nothing beats a good face-to-face discussion. Nothing beats the ritual of Rounds. We do hope, however, that these summary posts will:

  •  highlight a few key points from each session to bring those not in attendance into the loop
  • create space for ongoing discussion for those who wish they had added something to the conversation
  •  act as a space where we could request input from those outside of the department

This website will be junior resident led meaning that summaries from sessions will come be written by junior residents and approved by the seniors presenting. This process will provide active learning opportunities for juniors and a great way to start our involvement in these important departmental events.

Feedback

This website is a work in progress and designed with QEmerg residents, physicians and staff in mind. We want to know what you like and what you don’t. Any and all feedback welcome – help the ritual evolve!