Comments for Sinai EM Journal Club http://sinaiem.wordpress.com Emergency Medicine Discussion Forum Sat, 19 Jul 2008 08:26:41 +0000 http://wordpress.org/?v=MU Comment on Mad CAP Antics: Antibiotics Within 4 Hours by Gordon Bleil http://sinaiem.wordpress.com/2007/03/18/mad-cap-antics-antibiotics-within-4-hours/#comment-1576 Gordon Bleil Wed, 18 Jul 2007 17:23:18 +0000 http://sinaiem.wordpress.com/2007/02/10/mad-cap-antics-antibiotics-within-4-hours/#comment-1576 As caregivers we have a voice. We need to have the opportunity to manage the (limited) risk/benefit ratio to our patients advantage. There is no question it is easier to measure process than quality, but quality is what we seek. Speaking up of course places a burden on ourselves to be constructive. I have been told that one concept behind this particular issue, and some of the other current goals, is to catch 'the low hanging fruit', to improve quality by making simple changes that are easy to reach. Medicine is too human to make that a reasonable concept. As caregivers we have a voice. We need to have the opportunity to manage the (limited) risk/benefit ratio to our patients advantage. There is no question it is easier to measure process than quality, but quality is what we seek. Speaking up of course places a burden on ourselves to be constructive. I have been told that one concept behind this particular issue, and some of the other current goals, is to catch ‘the low hanging fruit’, to improve quality by making simple changes that are easy to reach. Medicine is too human to make that a reasonable concept.

]]> Comment on Mad CAP Antics: Antibiotics Within 4 Hours by clinton stanford http://sinaiem.wordpress.com/2007/03/18/mad-cap-antics-antibiotics-within-4-hours/#comment-1361 clinton stanford Thu, 05 Jul 2007 23:19:01 +0000 http://sinaiem.wordpress.com/2007/02/10/mad-cap-antics-antibiotics-within-4-hours/#comment-1361 I have had intractable hiccups for 13 yrs, can anyone help me? I have had intractable hiccups for 13 yrs, can anyone help me?

]]> Comment on About by Jon Brassey http://sinaiem.wordpress.com/about/#comment-1188 Jon Brassey Mon, 18 Jun 2007 08:34:47 +0000 #comment-1188 Hi! I run the EBM website the TRIP Database (www.tripdatabase.com). I've just come across your site and would love to add it to TRIP. I'm assuming you have no objections! Best wishes jon Hi!

I run the EBM website the TRIP Database (www.tripdatabase.com). I’ve just come across your site and would love to add it to TRIP. I’m assuming you have no objections!

Best wishes

jon

]]> Comment on Remedies for Intractable Hiccups by Jon Brassey http://sinaiem.wordpress.com/2007/04/10/remedies-for-intractable-hiccups/#comment-1179 Jon Brassey Sun, 17 Jun 2007 08:40:07 +0000 http://sinaiem.wordpress.com/2007/04/02/remedies-for-intractable-hiccups/#comment-1179 Hi! A quick search of TRIP (www.tripdatabase.com) found the following clinical guideline on hiccups - http://cks.library.nhs.uk/hiccups/view_whole_guidance Best wishes jon Hi!

A quick search of TRIP (www.tripdatabase.com) found the following clinical guideline on hiccups - http://cks.library.nhs.uk/hiccups/view_whole_guidance

Best wishes

jon

]]> Comment on SAEM followup by phil http://sinaiem.wordpress.com/2007/05/20/saem-followup/#comment-1027 phil Thu, 31 May 2007 00:08:46 +0000 http://sinaiem.wordpress.com/2007/05/20/saem-followup/#comment-1027 Now I know only toothbrush bristles are radioopaque... Now I know only toothbrush bristles are radioopaque…

]]> Comment on SAEM followup by phil http://sinaiem.wordpress.com/2007/05/20/saem-followup/#comment-1026 phil Thu, 31 May 2007 00:02:36 +0000 http://sinaiem.wordpress.com/2007/05/20/saem-followup/#comment-1026 I just saw Ted Melnick MD on Untold Stories of the ER.... What? I just saw Ted Melnick MD on Untold Stories of the ER….

What?

]]> Comment on SAEM followup by davidkpark http://sinaiem.wordpress.com/2007/05/20/saem-followup/#comment-949 davidkpark Tue, 22 May 2007 17:53:05 +0000 http://sinaiem.wordpress.com/2007/05/20/saem-followup/#comment-949 Congrats Nick! Congrats Nick!

]]> Comment on The Paining, Part I (Morphine in acute abdomen) by Lohness http://sinaiem.wordpress.com/2006/10/26/the-paining-part-i-morphine-in-acute-abdomen/#comment-947 Lohness Tue, 22 May 2007 15:10:13 +0000 http://sinaiem.wordpress.com/2006/10/26/the-paining-part-i-morphine-in-acute-abdomen/#comment-947 http://wapurl.co.uk/?CJ8UTOI good site http://wapurl.co.uk/?CJ8UTOI
good site

]]> Comment on SAH Update: Are New CT Scanners Good Enough to Obviate the LP? by Dave P http://sinaiem.wordpress.com/2007/05/07/sah-update-are-new-ct-scanners-good-enough-to-obviate-the-lp/#comment-782 Dave P Fri, 11 May 2007 08:27:33 +0000 http://sinaiem.wordpress.com/2007/05/07/sah-update-are-new-ct-scanners-good-enough-to-obviate-the-lp/#comment-782 One think I don't really understand, is how they got the lower CI for sensitivity to be 61%. Calculating CI when the incidence is low is tricky, and you can't use the same biostatistic calculation as one does for CI for greater numbers. A review of this is discussed in Annals EM, 30(3), 1997, pp 301-306. In short, 170 negative LPs after CT would indicate a lower limit sensitivity of 98.6%, (approx 3/171... see the article). Of note, the original studies that determined that "CT and LP" is safe to r/o SAH is based on "only" 199 patients total spread out over 4 different studies; the largest study is 77 patients. This data is prospectively collected and outcome based, but raises the same questions regarding the small size of the study. In the end, I'm not so concerned about the size of the study, but the fact that it wasn't prospectively collected. As Scott pointed out, the syndrome can easily be a spectrum which can affect our results, so I would be particularly interested in those patients who got CTs and did not get an LP for some reason, in order to make sure they didn't have any bad outcomes. Until then, I generally offer an LP to every r/o SAH headache patient, and discuss the currently available data with them. Patient autonomy can best balance the small risk of a SAH with the prospect of an LP. Just make sure you document the discussion. If the patient turns out to have a SAH, there's a decent chance he/she won't remember the conversation.... One think I don’t really understand, is how they got the lower CI for sensitivity to be 61%.

Calculating CI when the incidence is low is tricky, and you can’t use the same biostatistic calculation as one does for CI for greater numbers. A review of this is discussed in Annals EM, 30(3), 1997, pp 301-306.

In short, 170 negative LPs after CT would indicate a lower limit sensitivity of 98.6%, (approx 3/171… see the article).

Of note, the original studies that determined that “CT and LP” is safe to r/o SAH is based on “only” 199 patients total spread out over 4 different studies; the largest study is 77 patients. This data is prospectively collected and outcome based, but raises the same questions regarding the small size of the study.

In the end, I’m not so concerned about the size of the study, but the fact that it wasn’t prospectively collected. As Scott pointed out, the syndrome can easily be a spectrum which can affect our results, so I would be particularly interested in those patients who got CTs and did not get an LP for some reason, in order to make sure they didn’t have any bad outcomes.

Until then, I generally offer an LP to every r/o SAH headache patient, and discuss the currently available data with them. Patient autonomy can best balance the small risk of a SAH with the prospect of an LP.

Just make sure you document the discussion. If the patient turns out to have a SAH, there’s a decent chance he/she won’t remember the conversation….

]]> Comment on SAH Update: Are New CT Scanners Good Enough to Obviate the LP? by Scott http://sinaiem.wordpress.com/2007/05/07/sah-update-are-new-ct-scanners-good-enough-to-obviate-the-lp/#comment-751 Scott Tue, 08 May 2007 05:25:53 +0000 http://sinaiem.wordpress.com/2007/05/07/sah-update-are-new-ct-scanners-good-enough-to-obviate-the-lp/#comment-751 Nick raises some excellent points in the discussion of this article. This trial could have easily been done prospectively; it is a diagnostic study not a treatment study. You would just need to enroll all of the pts with cts ordered for SAH and then look at the LP results. If the clinicians decided for whatever reason not to perform an LP then you would need an alternative critierion standard such as follow-up. What many of these studies do not mention is that SAH is a disease whose tests exhibit a spectrum effect. The patients we feel definitely need an LP after their CT are the ones in which the CT is likely to be positive in the first place--the ones with striking, severe presentations. The patients with a subtle or crappy stories are the ones we often feel we can get away with skipping the LP after a negative CT. These patients are the ones the CT is likely to miss, because they may have only a scant amount of blood from a sentinel bleed. Spectrum effect messes with Bayesian reasoning b/c our pretest probability is not independent of the test. This, along with the reasons Nick mentioned, is why an LP still must follow your CT if you suspect SAH. At least, until more compelling data than this small study emerges. s Nick raises some excellent points in the discussion of this article.

This trial could have easily been done prospectively; it is a diagnostic study not a treatment study. You would just need to enroll all of the pts with cts ordered for SAH and then look at the LP results. If the clinicians decided for whatever reason not to perform an LP then you would need an alternative critierion standard such as follow-up.

What many of these studies do not mention is that SAH is a disease whose tests exhibit a spectrum effect.

The patients we feel definitely need an LP after their CT are the ones in which the CT is likely to be positive in the first place–the ones with striking, severe presentations.

The patients with a subtle or crappy stories are the ones we often feel we can get away with skipping the LP after a negative CT. These patients are the ones the CT is likely to miss, because they may have only a scant amount of blood from a sentinel bleed.

Spectrum effect messes with Bayesian reasoning b/c our pretest probability is not independent of the test. This, along with the reasons Nick mentioned, is why an LP still must follow your CT if you suspect SAH. At least, until more compelling data than this small study emerges.

s

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