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Showing posts from October, 2013

Transfusion Strategies for Acute Upper Gastrointestinal Bleeding

Landmark Series
Methodology Score: 3.5/5               Usefulness Score: 4/5
Villanueva C, Colomo A, Bosch A, Concepción M, Hernandez-Gea V, Aracil C, Graupera I, Poca M, Alvarez-Urturi C, Gordillo J, Guarner-Argente C, Santaló M, Muñiz E, Guarner C. N Engl J Med.2013 Jan 3;368(1):11-21
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This RCT comparing a restrictive versus liberal transfusion strategy (N=921) in acute upper GI bleeding showed that for patients who have rapid access to endoscopy (within 6 hours), a restrictive strategy (transfuse hgb < 7 g/dL) was associated with a higher probability of survival at 6 weeks (HR 0.55; 95% CI 0.33-0.92) and less adverse events (HR 0.73; 0.56-0.95) compared to a liberal strategy (transfuse hgb < 9 g/dL). This was the first large prospective RCT to address this issue and the group agreed that this was practice changing; however, it is difficult to apply the results of this study to those who have endoscopy after 6 hours.  By: Dr. Anita Lai (Presented June 2013)

Oral Dimenhydrinate versus Placebo in Children with Gastroenteritis: a Randomized Controlled Trial

Methodology Score: 2.5/5               Usefulness Score: 2/5
Gouin S, Vo TT, Roy M, Lebel D, Gravel J. Pediatrics. 2012 Jun;129(6):1050-5.
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This randomized, double-blinded, placebo-controlled trial of 144 children in Montreal found that the prescription of oral dimenhydrinate did not significantly decrease the frequency of vomiting in children with acute gastroenteritis compared with placebo (treatment failure rates 31% and 29%, respectively; absolute difference 0.02; CI 0.12-0.17). Journal Club attendees felt that despite this study's generalizability to our own local pediatric ED population, methodological flaws limited its usefulness (low power, unequal baseline characteristics, and multiple potential sources of bias). By: Dr. Tighe Crombie (Presented June 2013)

Epi Lesson: Sample Size in Clinical Trials

Diuretic Strategies in Patients with Acute Decompensated Heart Failure

Methodology: 3.5/5
Usefulness: 2/5 Felker GM, et al. NHLBI Heart Failure Clinical Research Network.
N Engl J Med.2011 Mar 3;364(9):797-805

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This double-blind double-dummy RCT (N=308) found that there was no difference in the patient global assessment of symptoms between furosemide infusion vs bolus (mean AUC, 4236±1440 and 4373±1404, respectively; P = 0.47), low dose vs high dose (mean AUC, 4430±1401 vs. 4171±1436; P = 0.06) and also no difference between the groups with regard to creatinine level at 72 hours. The group felt that this study is not practice changing for emergency medicine and had several problems (less sick patients not requiring vasodilators and O2 sat 96%; randomization occurred 14 hours after presentation; use of NIPPV not mentioned).  
By: Dr. Bader Al Yahya
(Presented June 2013)
Epi Lesson:Use of Continuous Data as Primary Outcome
Beware of studies that compare the effectiveness of interventions by using continuous data outcomes, such as pain scales (1-100), ox…