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Showing posts from 2014

Does This Adult Patient Have Septic Arthritis?

Methodology Score:    3.5/5                 Usefulness Score:  4/5
Margaretten ME, Kohlwes J, Moore D, Bent S. JAMA. 2007 Apr 4;297(13):1478-88.
Abstract Link
This 2007 systematic review found that (aside from specific clinical scenarios), history, physical exam and lab data were not particularly useful in confirming or ruling out the diagnosis of septic arthritis, and that suspected cases require synovial fluid analysis for better risk stratification. The group was disappointed the study was unable to guide avoidance of arthrocentesis, but found the study useful for informed discussions with consultants and for confirming the diagnostic difficulty of septic arthritis, even with synovial fluid analysis.  By: Dr. Michael Ho (September 2014)

Epi lesson:QUADAS-2 Tool for Evaluation of Systematic Reviews of Diagnostic Accuracy Studies

Fibrinolysis for patients with intermediate-risk pulmonary embolism

Methodology Score: 3.5/5               Usefulness Score: 3/5
PEITHO Investigators. N Engl J Med. 2014 Apr 10;370(15):1402-11.
Article Link

This multicentre double blind RCT focused on patients with submassive pulmonary embolism and the use of full dose tenecteplase (TNK) plus heparin versus placebo and heparin for the composite outcome of death or hemodynamic instability, Although the trial found an ARR of 3% in favour of TNK, JC attendees felt this was driven by the less important outcome of hemodynamic instability and thus was not enough to influence a change in practice.  By: Dr. Krishan Yadav (Presented June 2014)

Epi lesson: Composite Outcomes

Age-adjusted D-dimer cutoff levels to rule out pulmonary embolism: the ADJUST-PE study

Landmark Series
Methodology Score: 4/5                  Usefulness Score: 4.5/5
Righini M, et al. JAMA.2014 Mar 19;311(11):1117-24
Full Article
This prospective multicenter European prospective cohort study found that using age-adjusted D-Dimer cut off (age x10) in conjunction with the Wells or Geneva clinical decision rules increased the utility of the d-dimer to rule-out PE with an associated 11% absolute decrease in the unnecessary imaging. JC attendees agreed that this study is the first to address this question prospectively and if supported by robust future North American studies may lead to change in our current practice patterns. By: Dr. Elena Poliakova (Presented June 2014)

Epi lesson:  Consecutive Enrolment in Prospective Cohort Studies

Prospective multicenter evaluation of the pulmonary embolism rule-out criteria

Landmark SeriesMethodology Score: 4/5                 Usefulness Score:  4.5/5Kline JA, et al. J Thromb Haemost.2008 May;6(5):772-80. Full Article
In this prospective multicenter validation study, the PERC rule was found to have a sensitivity of 97.4% (CI 95.8-98.5%) and a negative likelihood ratio of 0.17 when applied to patients where physicians had determined that the pre-test probability of venous thromboembolism was low (<15%). Therefore, when a patient of low pre-test probability is found to be PERC negative, no further workup (including d-dimer) is needed to be able to say that and the chance that they will have a venous thromboembolic event in the next 45 days is less than 2%; although, JC attendees questioned whether the pre-test probability of a physician in American practice was equal to that of a physician seeing the same patient in Canadian practice.  By: Dr. Chris Fabian (Presented June 2014)

Epi lesson: Why 2X2 Tables are Important

2014 Canadian Guidelines for AF Management: Part 3: Unstable Patients with AF

by Ian Stiell MD @EMO_Daddy

We continue to discuss the latest recommendations for ED management of atrial fibrillation (AF) as presented in the newly published 2014 Focused Update of the Canadian Cardiovascular Society Guidelines for the Management of Atrial Fibrillation. The Guidelines PDF can be downloaded from the CCS website at 2014 Canadian Cardiovascular Society Guidelines for the Management of Atrial Fibrillation
Beware of Unstable Patients who are in Permanent AF! For patients whose recent-onset AF/AFL is the direct cause of instability with hypotension, acute coronary syndrome, or florid pulmonary edema, CCS recommends that immediate electrical cardioversion be considered if rate control is not effective or safe. Unless AF-onset was clearly within 48 hours or the patient has received therapeutic OAC for >3 weeks, CCS recommends immediate initiation of intravenous or low molecular weight heparin prior to cardioversion (if feasible) followed by therapeutic OAC for 4 weeks after…