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Showing posts from November, 2013

Validation of the Simplified Motor Score in the Out-of-Hospital Setting for the Prediction of Outcomes After Traumatic Brain Injury

Methodology score: 3/5                 Usefulness score: 2/5
Thompson DO, Hurtado TR, Liao MM, Byyny RL, Gravitz C, Haukoos JS. Ann Emerg Med. 2011 Nov;58(5):417-25
Article Link
This retrospective registry study demonstrated poor performance of either the Simplified Motor Score or GCS scores for predicting clinically important outcomes after traumatic brain injury when calculated by prehospital providers.  Journal Club attendees expressed reservations about the large proportion of missing GCS data in the study sample as well as the broader implications of losing clinically meaningful information with such a simplified score.  By: Dr. George Mastoras
(Presented September 2013)

Epi Lesson: Receiver-Operating Characteristic (ROC) Curves:
ROC curves are used to evaluate diagnostic data by plotting sensitivity versus 1-specificity, with higher areas under the curve (AUC) indicating better ability of the test to discriminate between patients with and without the condition. In this paper, the author…

Hydroxyethyl Starch 130/0.42 versus Ringer’s Acetate in Severe Sepsis

Landmark Series Methodology Score: 4/5                 Usefulness Score: 4.5/5
Perner A, et al.; 6S Trial Group; Scandinavian Critical Care Trials Group. N Engl J Med. 2012 Jul 12;367(2):124-34
Article Link
This multi-centre, double-blind, RCT found that resuscitation of severely septic patients with Hydroxyethyl Starch 130/0.42 conferred a greater risk of renal replacement therapy and of death at 90 days when compared to Ringer's acetate.  Despite concerns regarding extensive cross-over between groups and the possibility of treatment confounders which may inherently arise in pragmatic trials, the group was convinced that this study was effective in adding to the growing body of evidence against the use of synthetic colloids in sepsis.  By: Dr. Magdalena Kisilewicz (Presented September 2013)

Meta-analysis of Usefulness of D-dimer to Diagnose Acute Aortic Dissection

Methodology Score: 3/5                 Usefulness Score: 3/5
Shimony A, Filion KB, Mottillo S, Dourian T, Eisenberg MJ. Am J Cardiol. 2011 Apr 15;107(8):1227-34
Abstract Link
This meta-analysis of seven studies shows a pooled sensitivity (using random effects model) of 97% (94-99) negative LR 0.06 (0.03-0.12) specificity 56% (51-60) and positive LR 2.43 (1.89-3.12) for the use of D-dimer to rule out aortic dissection. The group was reluctant to recommend the use of D-dimer to rule out aortic dissection owing to poor methodologic quality of included studies, variations in D-dimer assays and a lack of validated risk stratification tools; a large multi-center prospective trial would be required for a definitive answer.  By: Dr. Michael Ho (Presented Sept 2013)

Epi Lesson: Heterogeneity of Studies in Overviews                               

Lactate Clearance vs Central Venous Oxygen Saturation as Goals of Early Sepsis Therapy: a Randomized Clinical Trial

Methodology Score: 3.5/5               Usefulness Score: 3.5/5
Jones AE, Shapiro NI, Trzeciak S, Arnold RC, Claremont HA, Kline JA; Emergency Medicine Shock Research Network (EMShockNet) Investigators. JAMA. 2010 Feb 24;303(8):739-46.
Article Link
This multi-centre, randomized, non-inferiority trial looked at using lactate clearance of 10% instead of ScvO2 as the tissue oxygen delivery target in early goal directed therapy for severe sepsis and showed a mortality difference of -6% (95% CI -3% to 15%; non-inferiority D -10%). Despite some limitations in the study, JC attendees were encouraged by the findings to support the use of lactate clearance in the ED instead of ScvO2 measurements for EGDT in severe sepsis and septic shock.  By: Dr: Andy Pan (Presented June 2013)

Epi Lesson: Equivalence or Non-Inferiority Trials