Acute Chest Syndrome (Sickle Cell Disease)

The newest edition of the Skeptics’ Guide to Emergency Medicine “Hot Off The Press” covers this article on sickle cell acute chest syndrome: 

http://onlinelibrary.wiley.com/doi/10.1111/acem.13048/abstract

The Hot Off The Press series allows you to comment and ask questions of the authors of the paper. The best comments will be included in the summary that accompanies the paper in Academic Emergency Medicine. Before we get to the paper, let’s do a quick review. Continue reading “Acute Chest Syndrome (Sickle Cell Disease)”

Articles of the month (November 2016)

It’s that time again. Sure, there may be a lot to do during the month of December, but what better way to procrastinate than to grab a mug of hot chocolate, sit down in front of the fire, and read about some evidence based medicine….

(If that doesn’t sound appealing, you could toss in some earphones while you do your holiday shopping and listen to me and Casey ramble about these papers in the audio version on the BroomeDocs podcast.) Continue reading “Articles of the month (November 2016)”

Articles of the month (October 2016)

The end of another month can only mean one thing: I have once again read too many articles, and I feel the need to share them all with you. I think there is an excellent spectrum of really interesting papers this month, and as always I discuss them at length with Casey Parker on the Broome Docs podcast. Continue reading “Articles of the month (October 2016)”

Hypertonic saline for elevated ICP (Articles of the Month special edition)

In the June edition of the articles of the month, I included a paper on hypertonic saline for the treatment of traumatic brain injury. My conclusion (and that of the paper’s authors) was that hypertonic saline did not seem to provide any benefit, either in terms of mortality, or even in terms of lowering intracranial pressure. My friend Scott Weingart pointed out that the paper might not actually support that conclusion. The problem was with the studies they included in the review (which I hadn’t read myself). This is probably an excellent lesson: reviews are nice as an introduction to a topic, but expert clinical practice really requires a familiarity with the original literature. For example, there are many reviews that conclude that tPa is excellent for ischemic stroke, but… well I guess I won’t get into that here. Anyhow, I promised to read the studies on hypertonic saline in a little more depth and post an update, so that is what follows.

Continue reading “Hypertonic saline for elevated ICP (Articles of the Month special edition)”

Articles of the Month (September 2016)

It’s time for another edition of the articles of the month. I didn’t come across as many papers worth sharing as I usually do, but there are still a few gems in there. The good news is it is a quick read. Once again, I will be discussing these papers with Casey Parker on the BroomeDocs podcast, and we would love to hear feedback about the audio version of these posts. Until next time….

Continue reading “Articles of the Month (September 2016)”

Articles of the Month (August 2016)

The best emergency medicine articles that I came across in August 2016

Welcome to another edition of my favorite emergency medicine articles of the month. Once again, there will be an accompanying podcast with the talented and insightful Dr. Casey Parker on the BroomeDocs website where we briefly discuss these articles. Continue reading “Articles of the Month (August 2016)”

High Sensitivity Troponin on the SGEM

It’s an SGEM hot off the press! That means that you can comment on this article, and potentially see your comments published next to the original article in the official version of Academic Emergency Medicine. I am also excited to be joining Ken Milne with Corey Heitz as the official co-hosts of the SGEM HOP AEM sessions.

This week, we discuss a new trial on high sensitivity troponin with the lead author and all round excellent chap Dr. Rick Body. Have a listen to the episode and post any questions or comments you have for Dr. Body on the website. It’s a great way to get involved in post-publication peer review. What to you think? Is a single negative high sensitivity troponin as a rule-out strategy ready for prime time?

Body R, Mueller C, Giannitsis E. The Use of Very Low Concentrations of High-sensitivity Troponin T to Rule Out Acute Myocardial Infarction Using a Single Blood Test. Academic emergency medicine. 2016. PMID: 27178492 [Available free, full text here]

This is a secondary analysis of a large, prospective observational cohort (as part of the TRAPID-AMI trial.) They looked at 1282 adult patients presenting to the emergency department with new onset chest pain or symptoms suggestive of acute coronary syndrome that had peaked in the last 6 hours. The were looking at a high sensitivity troponin T on arrival and the primary outcome was acute MI at admission. The major secondary outcome was MACE (major adverse cardiac events). For the primary outcome of acute MI, using the primary strategy of an initial hs-cTnT below the limit of detection (<5ng/L) and no ECG ischemia, the test characteristics are:

  • Sensitivity 99.1% (95%CI 96.7-99.5%)
  • Specificity 43.9% (95%CI 40.9-46.9%)
  • PPV 26.0% (95% CI 23.0–29.2%)
  • NPV 99.6% (95%CI 98.5–100.0%)
  • LR+ 1.76 (95%CI1.67 – 1.86)
  • LR – 0.02 (95% CI 0.01 – 0.09)

In terms of the secondary outcome of MACE, the total 30 day event rate was 1.3%. The actual numbers were 6 MACE events, including only one death, no AMI and 3 revascularizations. I have always had a problem with considering revascularization as a adverse event, as it is so subjective. We know that revascularization is only helpful in the setting of an MI, so if someone goes for revascularization and didn’t have an MI is that really an important outcome, or is it just over-treatment?

My bottom line: Well, I don’t have high sensitivity troponin available, so I don’t have a use for this yet. There is no such thing as 0% risk. I think this information can be used to start a conversation with your patients. Within the context of shared decision making, I already send many patients home after a single negative troponin.

Go check out the episode on the SGEM, put on your skeptical hat, and make sure to comment.