Sinai EM Journal Club

Fearless chief Ted has organized the first of our Tuesday Night Journal Clubs (with apologies to Sheryl Crow). The goal of these meetings is to informally discuss several relevant and provocative papers on a certain topic of interest in EM. Particularly, we wanted to give attendees a foundation in the literature, and some ammunition when dealing with other services. We picked a dinner theme, with an appetizer, main course, and dessert.

Our appetizer came from the classic JAMA Rational Clinical Exam series, “Does This Patient Have Appendicitis?” (Wagner et al. JAMA Nov 20 1996, Vol 276, No. 19, PMID 8918857). Some interesting and quotable tidbits from this comprehensive review:

• RLQ pain had a positive likelihood ratio of about 8, and negative LR of between 0 and 0.28
• Rigidity wasn’t very sensitive, but had a positive LR of 3.8
• Migration of pain had a LR of 3.2
• Psoas sign, rebound, guarding, nausea, vomiting, fever and anorexia had relatively unimpressive positive and negative LR’s. Having ‘no similar pain previously’ gave a negative LR of 0.32.

The main course and desert follows below!

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For the final journal club of the year, Ravi picked an article from Goldstein (and others)  entitled, “A Randomized Controlled Trial of Multi-Sliced Coronary Computed Tomography for Evaluation of Acute Chest Pain” (available from the Journal of the American College of Cardiology, 2007 Vol 49, No. 8, pp863-871).

It’s not the definitive, practice-changing study we’re waiting for, but it draws upon previous work (such as JAMA 2005; 293:2471-8) estabilishing multi-slice CT coronary angiography as effective in diagnosing occlusion, and attempts to compare the safety, efficacy and efficiency of MSCT against established protocols.

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At our last Journal Club, Tom presented a 2005 paper from JEM on new CT scanners in the evaluation of SAH. The paper was called Subarachnoid Hemorrhage Diagnosis By Computed Tomography and Lumbar Puncture: Are Fifth Generation CT Scanners Better at Identifying SAH? by Boesiger and Shiber, and it appears in Journal of Emergency Medicine (2005: Vol. 29, No. 1 pp23-27).

The article is motivated by the fact that 1% of headache patients in the ED have SAH. Most are traumatic, but those that aren’t are usually from Circle-of-Willis aneurysm ruptures, which often kill or disable otherwise healthy people. EM physicians hate that sort of unsettling risk, and the situation is further complicated by the 20-50% of SAHers who present with a sentinel bleed. So there’s a real opportunity to help some potentially moribund patients —  but if you ask most interns, they’ll say they’re shoving too many needles into the backs of people who probably just needed some exedrin.

Maybe we can change our practice, based on recent upgrades in CT scanner technology. These authors were the first to look at the new scanners with an eye toward sensitivity in SAH diagnosis. More below…

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