Time for another edition of the ‘old article dump’. One of the downsides of subscribing to more than 50 journal feeds is the huge number of interesting papers that I flag for later, but never find time to fully appraise. I have been clearing some of these old PDFs out of my computer, but I figured that if the titles caught my eye, you might find them interesting as well. I have not fully appraised these papers. I have scanned them once. Don’t take my summaries as definitive. If something catches your eye, grab the paper and read it for yourself before making any practice changes. (Really, I suggest doing that even when I write a full appraisal.)
Colchicine in Patients with Chronic Coronary Disease
Nidorf SM, Fiolet ATL, Mosterd A, et al; LoDoCo2 Trial Investigators. Colchicine in Patients with Chronic Coronary Disease. N Engl J Med. 2020 Nov 5;383(19):1838-1847. doi: 10.1056/NEJMoa2021372. Epub 2020 Aug 31. PMID: 32865380
This is an interesting paper to discuss, in that it shows an improvement in outcomes from coronary disease with daily colchicine use, however, it is too far from emergency medicine, and shouldn’t change practice, so I never did a full write up. The big issue, if this ever comes up, is that although the composite outcomes was positive, all cause mortality actually looks worse, which is the problem with combining a bunch of non-patient oriented outcomes into a single composite.
A blood test for CSF leak?
Arrer E, Meco C, Oberascher G, Piotrowski W, Albegger K, Patsch W. beta-Trace protein as a marker for cerebrospinal fluid rhinorrhea. Clin Chem. 2002 Jun;48(6 Pt 1):939-41. PMID: 12029013
This paper is sort of fascinating, but I will admit it is completely clinically irrelevant at this point. There is a pretty limited set of blood tests that we currently select among, but I think that causes me to under-estimate the tremendous number of molecules in the human body that could provide valuable clinical information. In this study, they discuss a protein found primarily in the CSF as a marker for CSF leak. One important clinical take home is that CSF leak results in meningitis for 10% of patients (I think I would have under-estimated the risk), and therefore is important to find and repair.
Doc, will I be able to play the piano? Depends, could you before?
Ware AL, McLarnon MJW, Lapointe AP, et al; Pediatric Emergency Research Canada A-CAP Study Group. IQ After Pediatric Concussion. Pediatrics. 2023 Aug 1;152(2):e2022060515. doi: 10.1542/peds.2022-060515. PMID: 37455662
I didn’t really expect concussion to impact intelligence, and definitely not the much more crude measure of IQ, so this paper didn’t make the cut for a full review, but it is a large prospective cohort of 866 children showing no change in intelligence test scores in the first weeks to months after a concussion.
UTIs (AKA false positives) in kids with bronchiolitis
Elkhunovich MA, Wang VJ. Assessing the Utility of Urine Testing in Febrile Infants Aged 2 to 12 Months With Bronchiolitis. Pediatr Emerg Care. 2015 Sep;31(9):616-20. doi: 10.1097/PEC.0000000000000359. PMID: 25834961
They keep publishing these studies, and I think it’s just to make me angry. They look at a bunch of kids with clinically evident bronchiolitis, gather their urine, and find cultures at the exact rate we would expect (consistent with previous studies that indicate that kids often have asymptomatic bacteriuria.) However, the authors always seem to get the conclusions wrong, assuming that these are real UTIs rather than false positives, and ultimately suggesting going after urines in kids with clear respiratory infections. That is, of course, preposterous. We know why these kids have a fever, and it has nothing to do with their urine. It’s that bucket full of snot they are trying to shoot into your face while you examine them. And even if they did have a UTI, in well appearing children, UTIs are not associated with any bad outcomes. Stop torturing these kids. UTIs are not a serious bacterial illness. Just stop
Steroids for pharyngitis
Hayward GN, Hay AD, Moore MV, et al. Effect of Oral Dexamethasone Without Immediate Antibiotics vs Placebo on Acute Sore Throat in Adults: A Randomized Clinical Trial. JAMA. 2017 Apr 18;317(15):1535-1543. doi: 10.1001/jama.2017.3417. PMID: 28418482
I didn’t end up including this in any of the bigger write ups, because I think we all already know that steroids decrease symptoms in pharyngitis. This isn’t the study we really need. We need a truly massive study powered to detect the rare but possible side effects from this approach. It is realy hard to counsel patients on harms and benefits, because we don’t have a great sense of the risk of things like peritonsilar abscesses when giving steroids to people with pharyngitis.
Yeah, AI is coming.. But don’t get too excited yet
Kanjee Z, Crowe B, Rodman A. Accuracy of a Generative Artificial Intelligence Model in a Complex Diagnostic Challenge. JAMA. 2023 Jul 3;330(1):78-80. doi: 10.1001/jama.2023.8288. PMID: 37318797
At some point I will probably need to do a deep dive into the capabilities of AI in medicine, and its potential harms. For now, the results seem mostly lackluster. This version looks pretty bad, including the correct diagnosis in the differential generated only 65% of the time, and placing it in the top position only 40% of the time.
Is your favourite shoulder reduction technique the best?
Gonai S, Yoneoka D, Miyoshi T, da Silva Lopes K. A Systematic Review With Pairwise and Network Meta-analysis of Closed Reduction Methods for Anterior Shoulder Dislocation. Ann Emerg Med. 2023 Apr;81(4):453-465. doi: 10.1016/j.annemergmed.2022.10.020. Epub 2023 Feb 15. PMID: 36797133
We’ve covered a few of these individuals studies in the past, and I don’t think any was strong enough to make me want to cover the systematic review. As long as you are using a nontraumatic reduction technique, I don’t think it matters that much which technique you use first, as long as you have multiple backup option, and some understanding of shoulder anatomy. In this analysis, the FARES and Davos (which, maybe because I am Canadian, I have always called the Whistler technique) were the winners.
