Case Scenario: A 66YO man presents with a 48hr history of fever, lethargy and headache. No significant past medical history. On physical examination he has a temperature of 38.8C, GCS 15, stiff neck on flexion and no rash. Urinalysis and CXR are normal. Laboratory testing reports an elevated WBC with a left shift. You decide he needs a LP to check for meningitis.

Question:  Can ultrasound be used to improve successful LP attempts?

Background: The following procedures may decrease the risk of post-LP headache. Listen to SGEM#34: This is Spinal Tap for all the details.

1. Small-gauge atraumatic needles
2. Reinsertion of the stylet prior to the removal of the spinal needle
3. Mobilization of patients after completing the LP

Reference:  Ultrasound imaging for lumbar punctures and epidural catheterisations: systematic review and meta-analysis. Shaikh F et al. BMJ 2013;346:f1720 doi: 10.1136/bmj.f1720

• Population: 14 studies (n=1334)
• Intervention:  U/S assisted LPs (5 studies) and epidurals (9 studies)
• Control: Unassisted
• Outcome: Reduction of failed attempts

Results: 

• Failed procedures 12 studies (n=1234) 79% RRR (95% CI: 57-90) NN 16 (95% CI: 12-25)
• Traumatic Procedures 5 studies (n=?) 73% RRR (95% CI: 33-89) NN 17 (95% CI: 11-44)

Authors Conclusion: “Ultrasound imaging can reduce the risk of failed or traumatic lumbar punctures and epidural catheterizations, as well as the number of needle insertions and redirections. Ultrasound may be a useful adjunct for these procedures.”

BEEM Comments: There was no blinding for the patients. This might effect subjective outcomes such as post-LP headaches. It would be easy to do a sham ultrasound. However, the lack of blinding should not effect objectives outcomes such as failed or traumatic attempts.

Only 5 of 14 studies were done for LPs with the rest for epidurals. Half of the patients in the studies were obstetrical patients. All the physicians involved were ultrasound ‘keeners”. These things weaken the external validity of the results to the emergency department setting.

BEEM Bottom Line: There needs to be an adequately powered blinded RCT of ED doctors on consecutive ED patients in need of an LP showing a difference in patient oriented outcomes. Until then we suggest maximizing the methods proven to improve LP technique before we start adding unproven modalities (Straus et al).

Case Resolution: You successfully perform the LP without an ultrasound and send off the CSF to the lab for analysis to rule out meningitis.

KEENER KONTEST: The hoser who won last week was Constant Coolsma from the Netherlands. He knew that Tim Horton was a Canadian ice hockey defence man who later founded a coffee house/doughnut shop named after him.

Be sure to listen to this weeks podcast for another chance to a cool skeptical prize. Email your answer to TheSGEM@gmail.com. Use “Keener Kontest” in the subject line. First one to email me the correct answer wins.

Follow the SGEM on twitter @TheSGEM and like TheSGEM on Facebook.

Remember to be skeptical of anything you learn, even if you heard it on The Skeptics Guide to Emergency Medicine. Have a great Father’s Day and talk with you next week.

Last week I attended the Canadian Association of Emergency Physicians (CAEP) meeting in Vancouver. It was a wonderful trip for a number of reasons. The first and most important reason was my 13 year daughter Sage accompanied me on the trip. It was so much fun to spend one-on-one father/daughter time with her. We visited family, biked around Stanley Park and spend the afternoon at the aquarium. Sage also made a great “plus-one” for the conference.

While at the CAEP conference we did THREE CanFOAMed initiatives:

1) BoB (Best of BEEM) Talk

Dr. Anthony Crocco, Peds EM guru, and part of the BEEM Dream Team and I gave a BoB (Best of BEEM) Talk.  We presented the top five adult and pediatric papers of the last year. The audience was amazing and enthusiastically participated in the talk. It was standing room only, spilled out into the hallway and people were dancing in their seats. We used social media (music, memes and videos) to teach core EBM concepts. It ended with the world premiere of the LMFAO video called “I’m and Emerg Doc and I Know It”.  This video celebrates being and emergency physician and was a unique way to recruit doctors to the Chatham-Kent Health Alliance. The video has gone fungal with about 4,000 views in one week. We hope it goes bacterial (more than 10,000 views) but shooting for viral may be unrealistic.

2) Great White North Vodcast:

A vodcast was also created at CAEP and posted on YouTube with the help of Brent Thoma. Brent was the winner of the prestigious CAEP Resident of the Year Award – well deserved. We interviewed four leaders in the CanFOAMed movement. This was done in the style of Bob and Doug McKenzie’s show on Second City TV (SCTV) called The Great White North. This SCTV show celebrated unique aspects of the Canadian experience.

“Bob and Doug play on the stereotypical Canadian image: the hoser. The segment was created after a request from the executives at the CBC (which aired SCTV) to include two minutes of broadcast that included specific, identifiable Canadian content. Thus Bob (Rick Moranis) and Doug (Dave Thomas) were born. They were a satirical projected image of the typical beer drinking, plaid and toque wearing, great white North residing Canadian citizen. Bob and Doug’s image of the Hoser is (for the most part) divorced from the reality of what a Canadian actually looks like, values, and how the act and speak. For any Canadian, the image of the Hoser is so clearly satirical and a joke, yet the stereotypes embodied by these characters still play a roll in the creation of the Canadian identity.”

We hope you enjoy watching our version of the Great White North and our attempt at CanFOAMed humour.

Here are the four individuals we interviewed on the Great White North parody show. Each was asked to discuss their FOAMed initiative while suggesting another FOAMed resource they found useful.

Chris Bond: SOCMOB (@SOCMOBEM)

The SOCMOB is a blog for all types of medical trainees, including nurses, EMS providers, RTs, med students, residents and staff/consultants. The goal is to address common medical myths/pseudoaxioms, as well as provide free open access medical education (FOAM) on a variety of ED/critical care topics.

Chris is an emergency medicine resident in Canada, and has a passion for medical education, teaching, EBM and FOAM. He made a very popular YouTube video explaining Wenckebach to the Justin Timberlake song Sexy Back.

Suggested FOAMed resource by Chris is EMCrit by Scott Weingart.

Elisha T: The Chart Review (@ETTube)

The Chart Review is a case based blog looking at cases Elisha has seen in the emergency department.

Elisha T is a community emergency physician in Canada. Interests include teaching and social media in medical education. Supporter of the #FOAM and #FOAMed (free open/online access medical education) movement.

Suggested FOAMed site ERCast by Rob Orman

Eve Purdy: Manu et Corde (@Purdy_Eve)

Manu et Corde blog was created to document life in medical school and Eve’s road to becoming a physician. It is a mix of personal reflections, FOAM designed as reference for other medical students/health professionals and commentary on medical education.

Eve is a Canadian medical student. Her recommended FOAMed site is The Short Coats in EM by Lauren Westafer.

Stella Yiu: Flipped EM Classroom (@Stella_Yiu)

The flipped classroom model is based on reversing the traditional approach to teaching. Stella does this project with Dr. Rahul Patwari from Chicago. The flipped model, as the name suggests, reverses this situation. Students review lecture material at home while they are alone. This passive activity is best done in isolation anyway. Homework is then completed in the classroom where students have the benefit of asking one another questions or drawing upon the knowledge of the instructor. The goal is to create a series of lectures based on the flipped classroom model using the curriculum created by the Clerkship Directors in Emergency Medicine.

Stella Yiu is an Assistant Professor in the Department of Emergency Medicine at the University of Ottawa. She is the Undergraduate Clerkship Associate Director. Stella is also one of the organizers of the CAEP 2014 meeting to be help in Ottawa. We hope she will build on the success of social media initiatives at CAEP 2013. Her suggested FOAMed site is Academic Life in Emergency Medicine by Michelle Lin.

Brent Thoma: BoringEM (@BoringEM)

The BoringEM blog was inspired by the realization that that the majority of Free Open-Access Meducation (FOAM) is about sexy stuff. Ultrasound and critical care are awesome, but the boring (but common and important) aspects of emergency medicine also need some love. This site attempts to fill that niche by publishing on EM topics of intense disinterest.

Brent is a Canadian ER resident that loves emergency medicine, simulation, education, mentorship, leadership, quality improvement, writing, parliamentary procedure, Star Wars, Dodgeball, his dog and a few people.

Brent recommends using GoogleFOAM to search out FOAMed resources on the internet.

Ken Milne: TheSGEM (@TheSGEM)

TheSGEM wants you to be able to give the BEST possible care to the patients you serve. It does this using social media to turn Med Ed on its head. Its goal is to shorten the knowledge translation window from about ten years down to one year. The high-quality, clinically relevant content comes from the Best Evidence in Emergency Medicine (BEEM) faculty who critically appraise the literature. Listen to TheSGEM and turn your car into a classroom.

I am a front line emergency room physician practicing for 16 years in small rural community. Married with three wonderful children and a dog. Been doing medical research for 30 years. Passionate about teaching. Struggling to stay physically fit by doing endurance sports.

VIEW Vodcast on YouTube of TheSGEM Episode#40: Great White North

3) RANThony:

Continuing along with the Canadian content and the focus on CanFOAMed we created our 1st RANThony. Dr. Anthony Crocco  has been know for his teaching rants on various paediatric emergency medicine topics. We decided that doing a video similar to the rants done by Rick Mercer a famous Canadian political satirist would be a great idea. Check out Rick’s Rant on the Flu Shot to understand what we were trying to achieve.

CAEP offered the perfect opportunity to record a RANThony. So during lunch one day we walked through the vender display hall and Anthony gave his Fever Fear Rant.  Please send us your feedback and let us know if you would like to see more RANThonies in the future.

KEENER KONTEST: Last week’s winner was Dave Lemonick from Pittsburgh. The question was about the origins of Memorial Day in the USA. Dave answered correctly that Memorial Day was officially proclaimed on 5 May 1868 by General John Logan. He was a national commander of the Grand Army of the Republic, and it was first observed on 30 May 1868, when flowers were placed on the graves of Union and Confederate soldiers at Arlington National Cemetery. Dave you will be receiving a cool skeptical prize.

Be sure to listen to this weeks podcast for another chance to win. Email your answer to  TheSGEM@gmail.com. Use “Keener Kontest” in the subject line. First one to email me the correct answer wins.

Remember to be skeptical of anything you learn, even if you heard it on The Skeptics Guide to Emergency Medicine.  Talk with you next week.

LMFAO: I’m an Emerg Doc and I Know It YouTube Link

Guest Host: Dr. Chris Carpenter

Case Scenario: 40yo construction worker presents to the emergency department with a swollen and painful right knee. No history of injury. No significant past medical history. Palpable effusion on examination with no overlying redness or warmth to touch. Any movement of the joint is very painful. He is taking no medications. Vital signs are normal.

Question:  What history, physical or diagnositc studies can help in the diagnosis of septic arthritis?

Background: There are many causes for monoarticular arthropothies which present to the emergency department. These include trauma, rheumatoid, lupus and infectious (viral, fungal, and bacterial). Septic arthritis due to bacteria has an incidence rate of 10 per 100,000 each year in the USA. The incidence is higher in patients with prosthetic joints or pre-existing rheumatoid arthritis. Immunocompromised patients with HIV are also at increase risk of septic arthritis.

Septic Monoarticular Arthropothies:

• Knees (50%)
• Hips, shoulders and elbows
• Any joint can ultimately be infected

Prompt diagnosis and appropriate treatment is required to prevent morbidity and mortality. Previous research has suggested that most cases of acute monoarticular arthropoties can be diagnosed using history, physical examination and diagnostic testing in three days. However, most emergency physicians only have a few hours not three days to differentiate between septic and non-septic arthritis.

Reference:  Carpenter CR et al. Evidence-based Diagnositcs: Adult Septic Arthritis. Academic Emergency Medicine 2011

• Population: Adult patients
• Intervention: History and physical examination and laboratory testing (serum and synovial)
• Control: Unaided clinical gestalt
• Outcome: Diagnostic accuracy (sensitivity, specificity and likely hood ratios)

Results: Prevalence of non-gonococal septic arthritis in the ED patients

EBM Extras:

• MOOSE Criteria: Meta-analysis of Observational Studies in Epidemiology (MOOSE) statement is intended for the reporting of meta-analyses of observational studies.
• QUADAS: Quality Assessment of Diagnostic Accuracy Studies (QUADAS). This is an evidence based quality assessment tool to be used in systematic reviews of diagnostic accuracy studies.
• STARD Criteria: Standards for Reporting Studies of Diagnostic Accuracy (STARD). The objective of the STARD initiative is to improve the accuracy and completeness of reporting of studies of diagnostic accuracy, to allow readers to assess the potential for bias in the study (internal validity) and to evaluate its generalisability (external validity).

Authors Conclusions: “Recent joint surgery or cellulitis overlying a prosthetic hip or knee were the only findings on history or physical examination that significantly alter the probability of nongonococcal septic arthritis. Extreme values of sWBC (>50 · 109 ⁄ L) can increase, but not decrease, the probability of septic arthritis. Future ED-based diagnostic trials are needed to evaluate the role of clinical gestalt and the efficacy of nontraditional synovial markers such as lactate.”

BEEM Comments: 

• Limited search to English
• Low to moderate QUADAS scores
• Excluded gonococcal infections
• Lacked definitive septic arthritis treatment randomized controlled trials
• No patient-centred outcomes reported

BEEM Bottom Line: When it comes to the accuracy of history, physical examination, serum tests or synovial tests for the diagnosis of septic arthritis in ED patients we just don’t know but synovial lactate looks promising.

Case Resolution: You successfully tap the knee and send the synovial fluid off for examination. Orthopaedics is consulted. Three days later you get the lab tests back describing  urate crystals consistent with gout.

KEENER KONTEST: Last week’s winner was Dr. Chris Edwards from Australia. I challenged TheSGEM listeners to come up with some ED themed memes.  A meme is “an idea, behavior, or style that spreads from person to person within a culture.” A meme acts as a unit for carrying cultural ideas, symbols, or practices that can be transmitted from one mind to another through writing, speech, gestures, rituals, or other imitable phenomena. Supporters of the concept regard memes as cultural analogues to genes in that they self-replicate, mutate, and respond to selective pressures.

Be sure to listen to this weeks podcast for another chance to a cool skeptical prize. Email your answer to  TheSGEM@gmail.com. Use “Keener Kontest” in the subject line. First one to email me the correct answer wins.

Remember to be skeptical of anything you learn, even if you heard it on The Skeptics Guide to Emergency Medicine.  Talk with you next week.

This week I had the pleasure of giving a keynote address on social media and rural medicine. The cool thing about it was giving it virtually. I was in Goderich, Canada and the presentation was streamed live to Adelaide, Australia. Social Medial is shrinking the world. Viva FOAMed.

Because of the keynote address I did not have time to put together the traditional SGEM podcast. With your permission I will share the keynote address with you. If interested, you can check out the YouTube video prepared for the conference.

Social Media Presentation:

1. Definition of SoMe: “The means of interactions among people in which they create, share, and exchange information and ideas in virtual communities and networks.” Ahlqvist, Toni; Bäck, A., Halonen, M., Heinonen, S (2008). “Social media roadmaps exploring the futures triggered by social media”. VTT Tiedotteita – Valtion Teknillinen Tutkimuskeskus (2454): 13.
2. Knowledge Translation Problem: Pathman Leaky Pipe (Awareness, Acceptance, Applicable, Able, Act On, Agree, Adhere)
3. Examples of SoMe: Podcasts, Twitter, YouTube, Facebook and Meme
4. Solution to KT Problem: The Skeptics Guide to Emergency Medicine
5. New SoMe Project: Just Out of the Gate (JOG)

Some Cool FOAMed Sites Down Under:

• Broomedocs: Free educational blog for rural GP and proceduralists. Country docs are “jacks of all trades”, GPs, Anaesthetists, part-time intensivists, O&G, Paeds, Psych ….  basically the doctors in the country who have to deal with whatever rolls in the door.
• Ruraldoctors: This site is for rural doctors who want to keep in touch with the latest in FOAMed concepts relevant to rural practice, listen to relevant podcasts and share thoughts on typical cases – using the info from the wider FOAMed community. Rural Doctors are a disparate bunch. Whilst I reckon that rural medicine is one of the best jobs in the world due to the sheer diversity (primary care, emergency medicine, obstetrics, anaesthetics), it can be hard for the isolated rural doctor to keep up to date.

KEENER KONTEST: We have three prizes for this week. The first prize goes to Dr. Tony Lain-Llyod (Dr. Crocodile Dundee) for being such a good sport. The next prize goes to Dr. Mohammed Alomar for being the first person from Saudi Arabia to play the keener kontest. And the finally, Dr. Crispen Richards from London, Canada. He identified hemotympanic membrane as a physical sign suggesting basilar skull fracture.

This weeks Keener Kontest is to make a Meme about working in the ED. You can download some free apps to help you or go to Quick Meme or Meme Maker. Email your creation to TheSGEM@gmail.com. Use “Keener Kontest” in the subject line. I will use the really good ones in my presentation next week at CAEP in Vancouver with Dr. Anthony Crocco. We are giving the Best of BEEM (BoB) talk at the meeting. You will be given credit for your meme and will be sent a cool skeptical prize.

Remember to be skeptical of anything you learn, even if you heard it on The Skeptics Guide to Emergency Medicine. Talk with you next week.

Case Scenario: An otherwise healthy 21yo male patient who has been drinking alcohol all day at the beach. He tries to jump into the back of his friends moving Jeep and does a face plant. He arrives by ambulance GSC 15 collar and boarded with racoon eyes. Because your small hospital does not have a CT scanner you ship him out for the CT head which shows a non-displaced basilar skull fracture. You admit him to hospital for neurological observation while the alcohol wears off. You wonder should you start prophylactic antibiotics to prevent meningitis?

Question:  Are prophylactic antibiotics effective in preventing meningitis in patients with basilar skull fractures?

Background: Basilar skull fractures from non-penetrating head trauma is estimated to by about 10%. Cerebral spinal fluid leakage associated basilar skull fractures is also about 10% with a range from 2-20%. The concern with basilar skull fracture is the direct contact of bacteria in the paranasal sinuses, nasopharynx or middle ear could predispose patients to meningitis. Physicians often give prophylactic antibiotics to decrease the risk of meningitis in these cases.

Signs/Symptoms of a Basilar Skull Fracture:

• Battle Sign
• Hearing loss
• Tympanic membrane perforation
• CSF otorrhea/rhinorrhea
• Bilateral periorbital eccymosis (Racoon eyes)
• Peripheral facial nerve palsy
• Vestibular dysfunction
• Anosmia

Reference:  Ratilal BO, Costa J, Sampaio C, Pappamikail L. Antibiotic prophylaxis for preventing meningitis in patients with basilar skull fractures. Cochrane Database of Systematic Reviews 2011, Issue 8. Art. No.: CD004884.

• Population: Patients of any age with recent basilar skull fracture. 5 RCT’s (N=208) and 17 non RCTs (N=2168) analyzed separately.
• Intervention: Prophylactic antibiotics administered at the time of primary treatment of basilar skull fracture. n=109
• Control: Placebo n=99
• Outcome: Primary: Menigitis suspected clinically and confirmed by lumbar puncture. Secondary: All-cause mortality/meningitis-related mortality. Need for surgical correction in patients with CSF leakage. Non-CNS infection.

Results: 5 RCTs (n=208) and 17 non-RCTs (n=2168)  All 208 participants from the 5 RCTs included in the meta-analysis. There were no significant differences between the two groups (antibiotic prophylaxis vs. and control). This included the primary outcome of meningitis and all the secondary outcomes (all-cause mortality, meningitis-related mortality, and need for surgical correction in patients with CSF leakage). A meta-analysis of the non-RCT had results similar to the RCT data. No adverse effects were reported with the use of antibiotic.

Authors Conclusions: “Currently available evidence from RCTs does not support prophylactic antibiotic use in patients with BSF, whether there is evidence of CSF leakage or not. Until more research is completed, the effectiveness of antibiotics in patients with BSF cannot be determined because studies published to date are flawed by biases. Large, appropriately designed RCTs are needed.”

BEEM Comments: The studies included in this review all had important methodological flaws. Curiously, the frequency of meningitis in the Eftekhar 2004 trial was significantly higher than in the other trials. This may be because they only enrolled patients with a basilar skull fracture and pneumocephalus. This could represent patients at higher risk for developing meningitis. There was no difference overall in the frequency of meningitis in the prophylactic antibiotic group versus the control group, even when the subgroups with and without CSF leakage were analyzed. There was a possible adverse effect of increasing susceptibility to infection with more pathogenic organisms in those treated with antibiotics. None of the studies reported data on outcomes of safety and tolerability of prophylactic antibiotics.

BEEM Bottom Line: There is no support for routine prophylactic antibiotics in all patients with basilar skull fracture. Further RCTs are needed to assess its benefits and risks clearly.

Case Resolution: You decide not to give prophylactic antibiotics to this young man who tried to jump into a moving vehicle and sustained a basilar skull fracture.

KEENER KONTEST: Last week’s winner was Chris Bond from Saskatoon and responsible for SOCMOB blog. He is TheSGEMs first repeat winner. Chris suggested Doxycycline 100 mg po BID as a nice choice for community acquired pneumonia in a 66yo woman on a calcium channel blocker as recommended by IDSA guidelines (Grade III rec) as alternative to Macrolide.

Be sure to listen to this weeks podcast for another chance to a cool skeptical prize. Email your answer to  TheSGEM@gmail.com. Use “Keener Kontest” in the subject line. First one to email me the correct answer wins.

Dr. Anthony Crocco and I will be presenting the Best of BEEM at this years CAEP meeting in Vancouver next month. Please come by and say hello. If you are not attending this year than follow on Twitter @TheSGEM and Facebook.

Remember to be skeptical of anything you learn, even if you heard it on The Skeptics Guide to Emergency Medicine. Be safe this holiday long weekend. Talk with you next week.

Case Scenario: 67 year-old woman presents with a one week history of productive cough and no fever. She is a non-smoker and has no history of lung disease. Her past medical history is positive for hypertension and she is taking a calcium channel blocker. She has no allergies to medication. On exam she has no fever, oxygen saturation is 97% on room air, and has clear air entry. Xrays is reported as slight patchy infiltrate in right lower lobe possible early pneumonia.

Question:  Do macrolides cause serious hypotension in patients on CCBs?

Reference:  AJ Wright et al.  CMAJ, February 22, 2011;183(3)

• Population: Patients 66+ years old admitted to hospital with a diagnosis of hypotension or shock (ICD-9 codes) while receiving a CCB (n=7,100) between 1994-2009. There was a almost 1 million patients who received single CCB during study period.
• Intervention: Prescription of macrolide in the 7 days before admitted to hospital
• Control: Each person served as there own control. Patients on CCBs were contrasted to exposure 7 days prior to admission with  7 d­day control period one month earlier.
• Outcome: Hypotension or shock resulting in hospital admission

EBM: Case-crossover design was used in this study. These types of studies have some advantages over a randomized  longitudinal study. In crossover trials each patient serves as their own control reducing confounding influence of confounding covariates. The design is also more statistically efficient and so require fewer subjects.

“A case-control design involving only cases may be used when brief exposure causes a transient change in risk of a rare acute-onset disease.” Maclure Am J Epidemiol 1991

Results: 176 patients of the 7,100 had received a macrolide during either the risk or control intervals.

Authors Conclusions: “In older patients receiving a calcium-channel blocker, use of erythromycin or clarithromycin was associated with an increased risk of hypotension or shock requiring admission to hospital. Preferential use of azithromycin should be considered when a macrolide antibiotic is required for patients already receiving a calcium-channel blocker.”

BEEM Comments: Calcium channel blockers (CCBs) are the ninth most commonly prescribed class of drugs in the USA with almost 90 million prescriptions in 2008. Macrolides are the most commonly prescribed class of antibiotics in the USA with over 66 million prescriptions in 2008. They both are effect the cytochrmome P450 system (specifically the isoenzyme 3A4). This raised the possibility of complications in addition to several case reports of such. This study of seniors from 1994 to 2009 identified almost one million patients who were prescribed a single CCB. During that time 7,100 patients were admitted to hospital for treatment of hypotension. There were 176 patients had also received a macrolide showing a strong association between erythromycin and clarithromycin use. No association was found with azithromycin (does not work through the same P450 system).

BEEM Bottom Line: If prescribing a macrolide antibiotic to a patient 66+ years old pick azithromycin or risk admitting them on your next shift for hypotension/shock.

Case Resolution: You diagnose the patient with community acquired pneumonia and prescribe a course of azythromycin. 

KEENER KONTEST: Last week’s winner was Nadia Awad from New Brunswick New Jersey. She is a PGY2 Emergency Medicine Pharmacy Resident at the Ernest Mario School of Pharmacy. Nadia correctly identified the hash tag for health care discussion in Canada as #HCSMCA.

Be sure to listen to this weeks podcast for another chance to a cool skeptical prize. Email your answer to  TheSGEM@gmail.com. Use “Keener Kontest” in the subject line. First one to email me the correct answer wins.

Follow the SGEM on twitter @TheSGEM and like TheSGEM on Facebook.

Remember to be skeptical of anything you learn, even if you heard it on The Skeptics Guide to Emergency Medicine. Talk with you next week.

This is a follow-up to Episode#30: My Generation. Every five episodes or so I like to deviate from the case based evidence based medicine (EBM) formula where we critically review an article or topic.

The goal of TheSGEM however remains the same, to cut the knowledge translation (KT) window from 10 years to 1 year. This is so you the listener can provide the best EBM care to the patients you treat. It uses social media to turn Med Ed on its head.

TheSGEM is part of the Free Open Access to Medical Education or FOAMed. Episode 30 was well received. It looked at the generational tension the SGEM has created between baby boom faculty and Gen Y learners. These two groups have different priorities, styles, and goals among other things. Information technology and specifically social media has been embraced by the Gen Ys more so than the boomers.

TheSGEM has empowered students to have the latest, greatest, EBM in the palm of their hand. They also can listen to the podcast when working out or turn their car into a classroom. And while they may have the information readily available in the lecture hall or at the patients bedside they may also lack the experience to put this information into perspective.

Episode 30 discussed these issues BUT and yes there is a BUT, one of TheSGEMs skeptical listener (and she knows who she is) correctly pointed out two things. The first was that all the guest on the show were boomers. The second constructive criticism was that they were all men. So I have searched high and low for a group of Gen Yers to provide that “fair and balanced” perspective.

Today have three very bright and talented students joining TheSGEM. Alia taught the twitter lecture at the Society of Rural Physicians of Canada(SRPC) meeting last month in Victoria BC. I was immediately impressed with her and enjoyed the presentation. Hope you didn’t mind I was tweeting through the whole lecture. Jimmy a medical student who will be working with me this summer on a new social media project we are launching this fall. And Beth is the third guest who I also met at SRPC and went wow! She attended my lecture on social media, kept me on my toes, how, by asking questions and being a skeptical. Yes she is Gen Yer who is skeptical of all this social media stuff and how it fits into medical education and life.

Alia the twitter expert (@alia_dh):

• How do you see twitter fitting into medical education?
• Do you think you can teach complicated topics like medicine in 140 characters or less?
• Do you think it is rude to twitter during lecture?
• How about on clinical rounds?
• How does it make you feel when a patient twitters during visit?

Jimmy the social media machine (@Jimmy_Yan):

• What pod casts would you recommend? Surgery 101 and JMTM podcast
  
• How do you handle the issue of professors not being up to date?
• What expectation do you have that your professors to be up to date on the latest evidence based medicine?
• Do you think professors should be listening to pod casts and why?

Beth the social media skeptic:

• Why are you skeptical of social media?
• Do you think there is a role for social media in med ed?
• Do you think there should be course taught to students AND professors on social media?
• What do you think is the BEST aspect of social media?

BEEM Bottom Line: The #SoMe world is an extension of you as a learner; so as on the wards, be thoughtful, curious, respectful, humorous, and use good grammar!

KEENER KONTEST: Last weeks winner was my very first resident from years and years ago. And because he was my first resident that also makes him my # one resident. Super smart guy…Dr. Travis Nairn, of Owen Sound.  He correctly knew that the first person described in 1899 to have a post LP headache was Dr. Bier himself. Talk about commitment to research and talking one for the team.

Be sure to listen to for this weeks Keener Kontest question. If you are the first one to email me the correct answer at TheSGEM@gmail.com with “keener” in the subject line you will receive a cool skeptical prize.

Don’t forget to follow the SGEM on twitter @TheSGEM and like us on Facebook (it only takes one click).

Remember to be skeptical of anything you learn, even if you heard it on The Skeptics Guide to Emergency Medicine. Talk with you next week.

Case Scenario: A 66YO man presents with a 48hr history of fever, lethargy and headache. No significant past medical history. On physical examination he has a temperature of 38.8C, GCS 15, stiff neck on flexion and no rash. Urinalysis and CXR are normal. Laboratory testing reports an elevated WBC with a left shift. You decide he needs a lumbar puncture (LP) to check for meningitis.

Question:  How to perform the lumbar puncture

Reference:  Straus SE, Thorpe KE, Holroyd-Leduc J, “How do I perform a lumbar puncture and analyze the results to diagnose bacterial meningitis?” JAMA 2006, Oct 25;296(16):2012-2022

• Population: Adults patients undergoing diagnostic lumbar puncture (15 studies included)
• Intervention: Variations in techniques including positioning, needle type, stylet technique and post-procedure care
• Outcome: adverse post-LP patient events
• Analyses: LRs with 95% CI

Background: The first lumbar puncture was described by Quincke in 1891 to sample the cerebral spinal fluid. It has been used since as a diagnostic tool to evaluate the CSF for evidence of things including infection and subarachnoid hemorrhage. It was only a few years later that post LP headache was described in 1899 by Bier. While headaches are a common complication of LPs there are a number of rare adverse events: cerebral herniation, intracranial subdural hemorrhage, spinal epidural hemorrhage and infection.

A concern that often comes up in these cases is whether or not a CT needs to be done prior to performing the LP. This review article states that there is no evidence supporting universal neuroimaging prior to LP. They suggest the use of clinical judgement but that is not defined well. The two references given are Gopal et al 1999 and Hasbun et al 2001.

Gopal (n=113) had internal medicine residents not emergency physicians examine patients. The sample population had a median age of 42 with 36% immunocompromised and 46% had altered mentation.

Hasbun  (n=301) had emergency physicians or general internist evaluate the patients. The mean age was 40 with 25% being immunocompromised. Of the 301 only 235 got CTs prior to LPs.

Neither of these two studies have been validated prospectively in other independent populations.

This podcast will not be discussing the diagnostic accuracy of LP for meningitis or subarachnoid hemorrhage. The concept of whether or not you need to do an LP post CT to rule out a SAH has been debated lately (Newman’s 700 Club). SmartEM did a good podcast on this topic already.

Results: 

Operator Experience: No randomized studies, little evidence from lesser-quality studies to indicate any significant effect from experience.

Positioning of Patient: Unable to identify studies that evaluated the success of LP with different patient positions or the impact of patient positioning on the risk of adverse events. Note is made that maximal interspinous distance is achieved in the seated- with-feet-supported position from an n=16 physiologic measurement study.

Number of attempts: Nonsignificant increase (ARI 4.9%; CI: -13% to 3.4%) in risk of requiring 2 or more attempts when an atraumatic needle is used. No increased risk of backache despite this.

Needle Choice: Suggestion of (nonsignificant) decrease (ARR 12.5%, CI: -1.72% to 26.2%) in headache among patients in which an atraumatic needle is used (Figure 2), statistically significant heterogeneity primarily due to the inclusion of one small 1993 study. Single study, n=100, demonstrated a significant reduction in risk of headache (ARR 26%; CI: 11%-40%) with a 22 gauge Quincke needle instead of a 26 gauge Quincke needle.

Stylet Reinsertion: single study, n=600, concluded reduced risk of headache when stylet was reintroduced before needle withdrawal (ARR 11%; CI 6-5%-16%) but no details on randomization or blinding was available.

Bed rest post-LP: Four studies, n=717, no significant heterogeneity. Decrease in risk of headache with immobilization was nonsignificant (ARR 2.9%; CI: -3.4% to 9.3%)

Supplementary Fluids: No convincing evidence found.

Sudlow CLM, Warlow CP. Posture and fluids for preventing post-dural puncture headache. Cochrane Database of Systematic Reviews 2001, Issue 2. Art. No.: CD001790. DOI: 10.1002/14651858.CD001790.

Cochrane Conclusion: There is no good evidence from randomised trials to suggest that routine bed rest after dural puncture is beneficial. The role of fluid supplementation in the prevention of post-dural puncture headache remains uncertain. 

Authors Conclusions: “These data suggest that small-gauge, atraumatic needles may decrease the risk of headache after diagnostic LP. Reinsertion of the stylet before needle removal should occur and patients do not require bed rest after the procedure. Future research should focus on evaluating interventions to optimize the success of a diagnostic LP and to enhance training in procedural skills.

BEEM Bottom Line: The following procedures may decrease the risk of post-LP headache:

• Small-gauge atraumatic needles
• Reinsertion of the stylet prior to the removal of the spinal needle
• Mobilization of patients after completing the LP

Case Resolution: You perform a successful LP and send off the CSF to the lab for analysis to rule out meningitis.

KEENER KONTEST: There was no keener kontest question last year with the Boston Marathon episode.

Be sure to listen to this weeks podcast for another chance to a cool skeptical prize. Email your answer to  TheSGEM@gmail.com. Use “Keener Kontest” in the subject line. First one to email me the correct answer wins.

Follow the SGEM on twitter @TheSGEM and like TheSGEM on Facebook.

Remember to be skeptical of anything you learn, even if you heard it on The Skeptics Guide to Emergency Medicine. Talk with you next week.

Everyone has a story to tell. Their own perspective on the recent tragic events in Boston. It will impact us all in a unique way. Here is my way of remembering, honoring, saying thanks and trying to understand what happened. It is told through words, music, pictures and video.Boston 2013-Medium

As of today they have caught one person and killed another thought to be responsible for this horrific attack. We do not know what their motives or goals were.

I am absolutely sure their goals were not to make me feel closer to my best friend Rick who drove to Boston, ran the marathon and shared the experience. Not to strengthen my relationship with my beautiful wife Barb. And definitely not to cherish my children Ethan, Sage and Zoe more.

The event has also pulled me closer to all of you who were worried, tried to contact me and offered support.

I had the privilege of sharing the experience with an amazing group of runner from London, Ontario. They welcomed Rick and I into their world even if it was only for a brief time. Each one of these guys showed kindness and good hearted banter. It is easy to see why our friend Steve Beasley (Beaser) goes back year after year to run Heart Break Hill with these wonderful guys.

It was my first marathon. I was in the third wave of the last coral of the charity runners. Surrounded by people not driven by the clock but motivated by caring. Running for the memory of those lost to illness or trying to cure or prevent illness.

It was 4 hours of positive energy moving forward in a wave of resolute enthusiasm. I ran through all the little towns, did not kiss any girls from Wellesley College and survived the four big hills.

At mile 23 the Captain Kilometre cape came out to help me fly into the finish line. Beasley was there to cheer me on for the final 3 miles. Hugs, kisses and encouragement came from the cousins stationed at Mile 24. The same family who the day before played a game of soccer with me,went to Target to get poster boards for decoration and shared a large pasta dinner before the race. I made it into Boston feeling well at Mile 25. The roar of the crowd chanting “one more mile” was deafening. So deafening I did not hear the bombs explode…

The police stopped me at a barricade before I could turn right on Hereford and left on Boylston. My Garmin GPS watch said 480m to the finish line. It was not chaos. The first responders were amazing. The paramedics, police and fire fighters all ran towards the danger. They did what they were trained to do, put the lives of others before their own. The same courage was shown by the BAA volunteers and spectators who put themselves at risk to help strangers in need.

It will go on record officially as a DNF (did not finish)…No glory, no celebrating just somber reflection. I did however get a medal. This was from a very generous man who finished his 20th Boston Marathon. He said as far as he was concerned I completed the run, earned the recognition and he gave me his medal.

Our hearts may be breaking over the loss of life and those who survived with physical and mental injuries. However, the spirit of the many will not be broken by the horrible acts of a few. 

It is good to be back home safe. Happy to have been a witness to history rather than a victim of history. 

Will I be back next year to complete the 26.2 miles – I don’t know.

Will I forget – The Boston Marathon Bombing on April 15th, 2013 – Never. 

KEENER KONTEST: Last weeks winner was Dirk Chisholm from Calgary. He knew Boston was called beantown as baked beans were a staple in the diet of residents. They were baked in molasses due to a surplus caused by industries in Boston.

There will be no Keener Kontest this week. Be sure to listen to next weeks podcast for another chance to a cool skeptical prize.

Follow the SGEM on twitter @TheSGEM and like us on Facebook.

Remember to be skeptical of anything you learn, even if you heard it on The Skeptics Guide to Emergency Medicine. Thank you for letting me share my experience from Boston with you. Talk with you next week.

Case Scenario: A 46yo man presents to the emergency department doing the renal colic shuffle (not the Harlem Shake). He has a history of kidney stones. Nothing in his physical examination or investigations suggest anything other than another renal colic attack. He wants to know if there is a way to flush the stone out.

From TheSGEM Episode #04 (Getting Un-Stoned) you know that an apha blocker does not help pass stones beyond the placebo effect. We are still waiting for the big systematic review by Zhu from Cochrane on the topic.

Question:  Does pushing oral/IV or diuretics help in passing kidney stones?

Reference:  Worster AS, Bhanich Supapol W. Fluids and diuretics for acute ureteric colic. Cochrane Database of Systematic Reviews 2012, Issue 2. Art. No.: CD004926. DOI: 10.1002/14651858.CD004926.pub3.

• Population: Adults ED patients with acute renal colic
• Intervention: High volume IV or oral fluids or diuretic use
• Control: Placebo, no treatment or maintenance IV or oral hydration
• Outcome: Symptoms and duration, physician visits, hospital admit, surgical procedures or adverse events

Results: Two studies (n=118) looked at IV fluids

• No difference in pain at six hours (RR 1.06, 95% CI 0.71 to 1.57)
• No difference in stone clearance (1 study 43 participants: RR 1.38, 95% CI 0.50 to 3.84), hourly pain score or patients’ narcotic requirements (P >0.05 for all comparisons)
• No difference surgical stone removal (1 study, n=60: RR 1.20, 95% CI 0.41 to 3.51)
• No difference manipulation by cystoscopy (1 study, 60 n=60: RR 0.67, 95% CI 0.21 to 2.13)

Authors Conclusions: “We found no reliable evidence in the literature to support the use of diuretics and high volume fluid therapy for people with acute ureteric colic. However, given the potential positive therapeutic impact of fluids and diuretics to facilitate stone passage, the capacity of these interventions warrants further investigation to determine safety and efficacy profiles.”

BEEM Comments: 

• Two small studies (n=118)
• Lack of clinical evidence of benefit
• Theoretical potential harm (renal impairment or ureteric rupture from high volume IV)
• These treatments should not be routinely used

BEEM Bottom Line: You don’t need to push fluids (oral/IV) or use diuretics to pass kidney stones

Case Resolution: You treat him with some IV fluids and 30mg ketorolac IV. His symptoms resolve. Imaging demonstrates a small, distal stone with no hydronephrosis. He is instructed to return if new symptoms, existing symptoms get worse or he is worried. His follow up is with his primary care provider or urologist. 

KEENER KONTEST: Last weeks winner was Chris Bond. He is a Canadian EM resident, FOAMed blogger, dogma basher and wine and food supergeek. Chris was first to say fondaparinux 2.5mg sc daily for 45 days for the treatment of superficial thrombophlebitis to relieve symptoms and prevent extension to DVT/PE.

Be sure to listen to this weeks podcast for another chance to a cool skeptical prize. Email your answer to  TheSGEM@gmail.com. Use “Keener Kontest” in the subject line. First one to email me the correct answer wins.

Follow the SGEM on twitter @TheSGEM and take the time to click once and like TheSGEM on Facebook.

Be sure to listen to the podcast to hear this weeks Keener Kontest question.

Remember to be skeptical of anything you learn, even if you heard it on The Skeptics Guide to Emergency Medicine. Talk with you next week.

Case Scenario: A 58-year-old woman arrives to the ED with a painful leg. You do an appropriate history and physical examination. She is Well’s criteria low and PERC positive so you order a d-dimer. The d-dimer comes back elevated so you ask for an ultrasound. This imaging test comes back saying “no evidence of deep vein thrombosis”. You make the diagnosis of superficial thrombophlebitis.

Question: What should you do to treat this woman’s superficial thrombophlebitis (NSAIDs, coumadin, LMWH, surgery, nothing)?

Background: Superficial thrombophlebitis is a common problem usually involving the superficial veins of the leg. The two components of this condition are clot (thrombus) and inflammation of the vein (phlebitis). Besides local pain, superficial thrombophlebitis can cause red, itchy skin with hardening of the surrounding tissue. There has been a concern that superficial thrombophlebitis could lead to the more serious deep vein thrombosis.

Reference:  Di Nisio et a. Treatment for superficial thrombophlebitis of the leg. Cochrane Database of Systematic Reviews 2012, Issue 3. Art. No.: CD004982.

• Population: RCTs that included participants with a clinical diagnosis of superficial thrombophlebitis of the legs and objective diagnosis of a thrombus in the superficial vein. 26 trials involving 5,521 patients
• Intervention: Topical treatments, compression stockings/bandages, leg elevation, medical (LMWH, NSAIDs, unfractionated heparin, fondaparinux) and surgery (ligation, vein stripping, crossectomy)
• Comparison: Compared to another form of treatment, placebo or no intervention.
• Outcome: Symptoms, extension or recurrence of ST, progression to DVT/PE and quality of life. Secondary outcomes included mortality or adverse effects of treatment.

Results: Fondaparinux given for 45d, compared to placebo, reduced the composite primary end point (death, symptomatic PE/DVT, extension or recurrence of ST) by 85% (RR 0.15; 95% CI 0.08 to 0.26) with a NNT of 20 (95% CI, 15 to 25). Each component of this composite primary end point was reduced except for death. The risk of the composite of DVT or PE was also reduced by 85% (RR 0.15; 95% CI 0.04 to 0.50) with an NNT to prevent one PE or DVT of 88 (95% CI, 54 to 190). There was no increased risk of bleeding compared to placebo.

Fondaparinux: Synthetic factor Xa inhibitor. A potential advantage of fondaparinux is the lower risk for heparin-induced thrombocytopenia (HIT) compared to LMWH or unfractionated heparin . It needs to be used with caution in patients with renal dysfunction because of its renal excretion.There is a black box warning about epidural/spinal hematoma risk for fondaparinux.

Authors Conclusions: “Prophylactic dose fondaparinux given for six weeks appears to be a valid therapeutic option for ST of the legs.”

BEEM Comments: This is a typical Cochrane review with good methods addressing a common problem seen in the ED. The quality of most included trials was poor due to inadequately reported randomization and allocation concealment. One very large placebo controlled randomized trial (CALISTO, N=3002) dominated this SR, with over half of all the patients.

This systematic review showed fondaparinux worked. In the other smaller studies, LMWH or NSAIDs compared to placebo, appear to reduce the extension and recurrence of superficial thrombophebitis but had problems with methods and risk of increasing gastric complications. These studies showed no significant difference in the progression to PE or DVT. The evidence for topical treatment or surgery was too limited to draw any conclusions.

BEEM Bottom Line: : Fondaparinux SC OD for 6 weeks should be considered for treating thrombophlebitis of the leg.

Case Resolution: You treat this woman with Fondaparinux to relieve her symptoms and prevent extension to DVT/PE.

KEENER KONTEST: No winner last week:( It is always a challenge picking a question in the Goldie Locks Zone Question (not too easy, not too hard – just right). 

Be sure to listen to the podcast to hear this weeks Keener Kontest question. Email your answer to  TheSGEM@gmail.com. Use “Keener Kontest” in the subject line. First one to email me the correct answer wins.

Remember to be skeptical of anything you learn, even if you heard it on The Skeptics Guide to Emergency Medicine. Talk with you next week.

Guests:

• Dr. Chris Carpenter: Director Evidence Based Medicine, Wahington University
• Dr. Greg Polites Course Master Practice of Medicine, Washington University
• Dr. Peter Panagos Director of Stroke Network, Washington University

Case Scenario: Emergency Medicine resident approaches her staff physician after listening to an episode of TheSGEM. The information she is being taught by her supervisor is in conflict with what she had heard on the podcast.

Question: How does she deal with this situation?

Generational Learning:

Quotes from Ken:

• Disruptive Innovation: Disruptive innovation, a term of art coined by Clayton Christensen, describes a process by which a product or service takes root initially in simple applications at the bottom of a market and then relentlessly moves up market, eventually displacing established competitors.
• The medium is the message: A phrase coined by Marshall McLuhan meaning that the form of a medium embeds itself in the message, creating a symbiotic relationship by which the medium influences how the message is perceived.
• With great power, comes great responsibility: Said to Peter Parker by Uncle Ben. Stan Lee, the writer of Spiderman, may have borrowed this from Voltaire who said it in french years earlier.
• Master/Learner: The cycle is now complete. When I left you I was but the learner. Now I am the master. (Darth Vader)
• Competition: I think it inevitably follows, that as new species in the course of time are formed through natural selection, others will become rarer and rarer, and finally extinct. The forms which stand in closest competition with those undergoing modification and improvement will naturally suffer most.(Charles Darwin)

Additonal Resources:

• Healthy skepticism
• McMaster Evidence Based Clinical Practice
• NYAM TEACH course
• UCSF Evidence Based Diagnostics course
• 21st Century Flexner Report

KEENER KONTEST: This weeks winner was Jacqui Stuart a Nurse Practitioner from Chatham-Kent Health Alliance. She correctly identified the NINDS paper from NEJM 1995 Part 2 had a total of 333 patients. There was a 13% absolute benefit on the modified Rankin scale at 90 days of 13% and an absolute harm of 6% (symptomatic intra cerebral hemorrhage) .

Be sure to listen to the podcast to hear this weeks Keener Kontest question. Email your answer to TheSGEM@gmail.com. Use “Keener Kontest” in the subject line. First one to email me the correct answer will win a cool skeptical prize:)

Remember to be skeptical of anything you learn, even if you heard it on The Skeptics Guide to Emergency Medicine. Talk with you next week.

Click on the link JUMP to watch the YouTube video.

“Now everybody, Have you heard, If you’re in the game (of emergency medicine), Then the stroke’s the word, Don’t take no rhythm, Don’t take no style,  Gotta thirst for killin’, Grab your vial (of tPA) and stroke me, stroke me…”  Billy Squier The Stroke

Case Scenario: A 83-year-old woman arrives from home with right-sided weakness beginning 4h prior.  You diagnose acute ischemic CVA with no contra-indications to thrombolysis.

Question: Does thrombolysis given to acute ischemic CVA in <6hrs increase the proportion of people who are alive and independent at 6 months?

Background: Acute ischemic strokes represent the leading cause of disability in our society and the third most common cause of death. There have been many studies performed looking at thrombolysis for acute CVA. For a summary of the major tials check out Dr. David Newman’s Number Needed to Treat site. Another good review of the topic is a paper done by Dr. Chris Carpenter published in the Journal of Emergency Medicine.

When tPA was approved in the European Union it was restricted to 3 hrs and age less than 80 years old. A Cochrane review suggested that tPA might be beneficial up to 6hrs. Older people (>80) have been under represented in the previous tPA stroke trials. This set the basis for the study we will be talking about today. The IST-3 study was to establish the balance of benefits and harms of tPA in patients not meeting licence criteria (mainly older patients and up to 6 hrs).

Reference:  IST-3 Collaborative Group. The benefits and harms of intravenous thrombolysis with recombinant tissue plasminogen activator within 6 h of acute ischaemic stroke (the third international stroke trial [IST-3]): a randomised controlled trial Lancet 2012

• Population: Multi-centre, open-label, randomized control trial (n=3035)
• Intervention: tPA 0.9mg/kg
• Control: Placebo
• Outcome: Alive/independent on OHS at 6 months

Results: Total of 3035 patients (1515 treatment and 1520 control). 95% did not meet the European Union licence approved criteria. Over half (53% were >80 years old. Mean time to treatment was 4.2hrs.

• Primary Outcome: Alive/independent of activities of daily living (OHS 0-2) NO DIFFERENCE
  • 37%tPA vs 35% control with adjusted OR 1.13 (95% CI; 0.95-1.35)
• Harm:
  • Died at 7 days: 11%tPA vs 7% control with adjusted OR 1.6 (95% CI; 1.22-2.08)
  • Fatal or non-fatal ICH: 7% tPA vs 1% control with adjusted OR 6.94 (95%CI; 4.07-11.8)
  • Death 6 months: no difference 27% tPA vs 27% control
• Secondary Outcome: significant difference in ordinal shift
  • common OR 1.27 (95%CI; 1.10-1.47)

Authors Conclusions: “For the types of patient recruited in IST-3, despite the early hazards, thrombolysis within 6 h improved functional outcome. Benefit did not seem to be diminished in elderly patients.”

BEEM Comments: This was a pragmatic, multi-centre, randomized controlled, open-label trial. It sought to determine if older patients and patients treated <6hrs of CVA onset would benefit from tPA. The trial did not meet its target of 6,000 . The outcomes of patients >80yo were no different than those of younger patients. Also, patients treated with tPA >3hrs showed no significant benefit over those treated with placebo.

• The quotation “The lady doth protest too much, methinks.” comes from Shakespeare‘s Hamlet, Act III, scene II, where it is spoken by Queen Gertrude, Hamlet’s mother. The phrase has come to mean that one can “insist so passionately about something not being true that people suspect the opposite of what one is saying.” Wikipedia

Limitations and EBM Issues: There were many limitations to the IST-3 study. It represents an excellent opportunity to discuss a number of evidence based medicine issues.

1. Pragmatic trial

2. Open Label/Allocation Concealment
3. Only patients thought to benefit were included
4. Missed their target of 6,000 patients by 50%
5. After seven years they seemed to move the goal posts
6. Another statistician was brought in to “persuade” them
7. Big harm (death and bleeding)
8. Came up with a secondary outcome which was significant
9. Primary outcome showed NO DIFFERENCE
10. Was reported as a positive study????

BEEM Bottom Line: Treatment with tPA in this study harmed (death) 1 in 25 early, the fatal and non-fatal bleed rate when up significantly and there was no benefit seen at 6 months in the primary outcome.

Comments on IST-3 by other Experts:

• Newman Letter to Editor

• Fatovich Letter to Editor

• ISH-3 Study Reply

• EM Literature of Note

• Schrodinger’s Fence

• Hoffman EMA

• Fatovich EMA

Case Resolution: You discuss the options with the patient and their family. Given her age and the time now being over 4.5hrs you reach a shared decision not to use tPA.

KEENER KONTEST: Last weeks winner was Sam Brewer a PGY-4. He correctly identified that metoclopramide (Maxeran/Reglan) can cause extrapyramidal side effects like dystonia/tardive dyskinesia. The treatment for this feared reaction is diphenhydramine (Benadryl) or benztropine (Cogentin).

Be sure to listen to the podcast to hear this weeks Keener Kontest question. Email your answer to  TheSGEM@gmail.com. Use “Keener Kontest” in the subject line. First one to email me the correct answer wins.

Remember to be skeptical of anything you learn, even if you heard it on The Skeptics Guide to Emergency Medicine. Talk with you next week.

Case Scenario: 39yo woman known to your emergency department with a long history of migraine headaches presents in her usual way. There is nothing to suggest anything other than her typical migraine headache. You treat her successfully with IV fluids, DHE and metoclopramide. She is feeling much better and is ready for discharge.

Background: More than 10% of people (6% men and 18% women) suffer from migraines. This condition represents a significant source of both medical costs and lost productivity. Direct costs are estimated at ~17 billion dollars a year. There are also indirect costs of about 15 billion dollars a year mainly due to missed work. Up to half of patients presenting to the ED with their migraines will “bounce-back” to the ED in a few days. Dexamethasone has been tried in randomized control trials to prevent bounce-backs. Giuliano et al did a good review on this topic in Postgraduate Medicine last year.

Question: Can dexamethasone prevent migraine patients from bouncing back to the ED in the next few days?

Reference:  Coleman et al. Parenteral dexamethasone for acute severe migraine headache: meta-analysis of randomised controlled trials for preventing recurrence BMJ 2008;336:1359

• Population: Adult patients (>18 yo.) with acute severe migraine headache, meeting reasonable criteria to distinguish migraine from other non-migraine headaches. Seven studies were included in the meta-analysis (n=738)
• Intervention: Parenteral dexamethasone (in conjunction with acute abortive therapy); dosing variable
• Control: Placebo
• Outcome: Primary outcome was recurrence of migraine within 24-72hrs of treatment.  Secondary outcome was pain relief scores on 10pt VAS, and adverse events

Results: 

• Primary Outcome: Recurrence of migraine within 24-72hrs RR=0.74 (95% CI; 0.60-0.90) NNT=9 (95%CI; 6-25)
• Secondary Outcome: Pain relief score 10pt VAS was WMD=0.37 (95%CI; -0.20-0.94) NNT (not calculated)
• Adverse Events: 6 trials (n=626). Patients treated with dexamethasone were more likely to have dizziness (RR=2.15, 95%CI; 0.98-4.74) but less likely to have nausea (RR=0.70, 95%CI; 0.48-1.02) or “other” adverse events (RR=0.50, 95%CI; 0.30-0.82).

Authors Conclusions: “When added to standard abortive therapy for migraine headache, single dose parenteral dexamethasone is associated with a 26% relative reduction in headache recurrence (number needed to treat=9) within 72 hours.”

BEEM Comments: This review discusses the epidemiology and burden of migraine illness on health care systems and emergency departments. It also illustrates the potential public health and economic benefits of reducing these visits. Recurrent migraine is the second-most important therapeutic goal (after acute pain control) for migraineurs. It is a valuable endpoint from both patient and physician viewpoints. Dexamethasone is a cheap and easy medication to administer parenterally. Its relative risk reduction in early recurrent migraines of 26% with an NNT=9. There were no significant adverse effects and dexamethasone is readily familiar to most emergency physicians. There were some limitations with this review. What “reasonable criteria to distinguish migraine from other headache types” did the authors use?. Was it the International Headache Society criteria for migraine?. There was a failure to reference CONSORT guidelines for reporting studies. There was no assessment for publication bias (funnel plot). Regardless of these limitations, this review, provides information that should help emergency physicians treat these patients more effectively and reduce early recurrent migraine attacks and ED visits.

EBM Point: Consolidated Standards of Reporting Trials or CONSORT Statement. This was an initiative to try and address the problem of inadequate reporting of randomized control trials (RCTs). It consists of a check list of 25 items to standardize the way authors report clinical trial findings. This allows for transparency, critical appraisal and interpretation of the study. It also includes a flow diagram to show what happened to all the participants in the trial.

Washington University in St. Louis has an amazing Emergency Medicine Journal Club started by Capt. Cranium (Dr. Chris Carpenter). They did a great job looking at this literature and can provide more depth than this short podcast.

BEEM Bottom Line: For patients successfully aborted for a migraine attack, a single parenteral dose of dexamethasone ≥15mg will significantly reduce early recurrences (NNT=9) with no significant side effects.

Case Resolution: You discussed dexamethasone treatment with the patient. She decided it was worth a try and you give her 15mg of IV dexamethasone. You plan on checking to see if she re-presents in the next week.

KEENER KONTEST: Last weeks winner was Glenn Paetow. He correctly identified Wagner’s Grading Scale for Diabetic Foot Infections in our Bad to the Bone episode on osteomyelitis. Glenn will be receiving a cool skeptical prize for being so keen.

Be sure to listen to the podcast to hear this weeks Keener Kontest question. Email your answer to  TheSGEM@gmail.com. Use “Keener Kontest” in the subject line. First one to email me the correct answer wins.

Remember to be skeptical of anything you learn, even if you heard it on The Skeptics Guide to Emergency Medicine. Talk with you next week.

LYRICS AND VIDEO PRODUCTION BY: James McCormack

VOCALS BY: Shae Scotten and Liam Styles Chang — 2 guys from a great band called Aivia from Victoria, BC –  http://www.youtube.com/user/weareaivia

Case Scenario: 62yo man presents to the emergency department feeling weak. His vital signs at triage are normal but his glucometer reading is high. He is a known type 2 diabetic and states his sugars have been running a little high lately. After conducting an appropriate history and directed physical examination you have not yet determined the cause of his generalized weakness. There is nothing to suggest respiratory or urinary tract infection. Before leaving the room you take off his socks to check out his feet. What you see and smell is a diabetic foot ulcer on the plantar aspect of his left foot.

Background: Complications from diabetes are common presentations to the emergency department. These ED presentation will likely go up with the world wide prevalence of diabetes projected to increase to 333 million by 2025. More than 30% of diabetics in the US have lower extremity disease including 7.7% with ulcers. These ulcers can lead to infection, osteomyelitis and ultimately limb amputation. Diabetic patients are 10 times more likely than non-diabetics to require osteomyelitis-related limb amputations. The first step in preventing such amputations would be identify and treating patients with diabetes. Milne WK and Carpenter RC Annals of Emerg Med, May 2009

Reference:  Butalia et al. Does this patient with diabetes have osteomyelitis of the lower extremity? JAMA 2008;299:806-813

• Population: Diabetic patients with foot infections and suspected osteomyelitis
• Intervention: N/A
• Comparison: N/A
• Outcome: Diagnostic accuracy (sensitivity, specificity, likelihood ratio) for bedside physical exam, lab tests (WBC, ESR, CRP), plain film imaging, and other imaging tests

Results: No studies looked at the precision of signs or symptoms. Temperature was only reported in one poor quality study. It was possible to report the test characteristics of those shown below:

Authors Conclusions: “An ulcer area larger than 2cm, a positive probe-to-bone test result, an erythrocyte sedimentation rate of more than 70 mm/h, and an abnormal plain radiograph result are helpful in diagnosing the presence of lower extremity osteomyelitis in patients with diabetes. A negative MRI result makes the diagnosis much less likely when all of these findings are absent. No single historical feature or physical examination reliably excludes osteomyelitis. The diagnostic utility of a combination of findings is unknown.”

BEEM Comments: This review attempted to summarize the test characteristics of the history, physical examination, routinely available laboratory tests and imaging studies and MRI for diagnosing osteomyelitis in diabetic patients. The review had a number of limitations including a search strategy of English only manuscripts. Of the 21 studies included only 8 were prospective and 11 were judged to be of poor quality. “Clinical gestalt” was never clearly defined. No assessment of reliability (Kappa) for subjective measures were reported. None of these studies were ED based raising problems of external validity. No attempt was made to create a clinical decision rule/instrument using a combination of the tests. And finally, no patient oriented outcomes were assessed in this diagnostic accuracy study.

EBM Point:  This review included studies with verification/work-up bias. The diagnostic performance of a test is determined by comparing it to the gold standard or reference standard. This is most accurate established test for the disease in question. Bone biopsy was considered the reference standard for osteomyelitis in this review relative to ulcer size.

However, only those patients believed to have a high likelihood of disease are fully worked up (ie, undergo bone biopsy). This may mean that those patients with a positive result on the test being evaluated (ulcer size) are more likely to have the full evaluation, including bone biopsy, which leads to false “verification” of ulcer size by ensuring that those with larger ulcers are more likely to undergo bone biopsy, whereas those with smaller ulcers will either not be included in the data or will be presumed, perhaps falsely, to be disease negative. The main result of this bias will be incorrect elevation of the tests sensitivity and specificity.

To eliminate this work-up or verification bias all patients with diabetic foot ulcers regardless of its size would need to be biopsied for the presence of osteomyelitis. This would be both expensive and invasive making it making researchers less likely to obtain a bone biopsy.

BEEM Bottom Line: First thing to do when trying to diagnose osteomyelitis of the lower extremity is determining whether or not the patient is diabetic. An ulcer size of >2cm and a positive bone-to-probe test each significantly increases the LR of a DM osteomyelitis. Clinical gestalt was almost a useful as these two things. An ESR>70 strongly suggests the diagnosis in the correct clinical setting. An abnormal plain film can increase the probability, only MRI substantially reduces the LR. No single physical exam finding or test reliably excludes the diagnosis of osteomyelitis in a diabetic patient.

Case Resolution: You order standard blood work on this diabetic man including an ESR which comes back elevated at 77. Plain films are also performed showing some focal loss of trabecular bone and periosteal reaction. You make a diagnosis of osteomyelitis and start the man on appropriate antibiotics and consult orthopaedics.

KEENER KONTEST: No winner last week:(

Suneel Upadhye

Jo-Ann Talbot

Be sure to listen to the podcast to hear this weeks Keener Kontest question. Email your answer to  TheSGEM@gmail.com. Use “Keener Kontest” in the subject line. First one to email me the correct answer will win a cool skeptical prize:)

Remember to be skeptical of anything you learn, even if you heard it on The Skeptics Guide to Emergency Medicine. Talk with you next week.

Guest Skeptic: Dr. Anthony Crocco MD FRCPC, Deputy Chief, Pediatric Emergency Department, McMaster Children’s Hospital Assistant Clinical Professor, McMaster University, Member of the BEEM Dream Team.

Case Scenario: Five year old boy presents to the emergency department with a 2 day history of rhinorrhea and congestion. He has been coughing and it is especially bad at night. Mild fever is reported at home. He is eating and drinking well. On examination he looks well, is in no apparent distress and vital signs are all normal. Chest exam reveals no focal crackles or wheeze. You diagnose him with an upper respiratory tract infection (URI) ”cold”.

Dr. Anthony Crocco

Background: Brief differential diagnosis for child with cough presenting to the emergency department.

• Infectious:
  • Upper (pharangitis, otitis media, croup)
  • Lower (bronchiolitis or pneumonia)
• Non-Infectious:
  • Asthama
  • Foreign body aspiration
  • Gastro esophageal reflux disease (GERD)

Question: Do Over the Counter (OCT) medications work for cough in Children and Adults?

Reference: Smith et al. Over-the-counter (OTC) medications for acute cough in children and adults in ambulatory settings. Cochrane Database of Systematic Reviews 2012, Issue 8. Art. No.: CD001831. DOI: 10.1002/14651858.CD001831.pub4.22895922

• Population: 18 adult and 8 children trials with total of 4,037 patients
• Intervention: Variety ofOTC cough medications
• Comparison: Placebo
• Outcome: Symptom relief of cough

Results: Pharmaceutical industry sponsored 11 of the 26 trials. Eight of the 11 industry sponsored trials showed positive results and only 3 of the non-industry sponsored trials showed benefits.

Authors Conclusions: There is no good evidence for or against the effectiveness of OTC medicines in acute cough. The results of this review have to be interpreted with caution due to differences in study characteristics and quality. Studies often showed conflicting results with uncertainty regarding clinical relevance. Higher quality evidence is needed to determine the effectiveness of self care treatments for acute cough.”

BEEM Comments:  Heterogenicity was too high to perform a meta-analysis in this systematic review. The overall results of the review was that there was insufficient evidence that cough medicines provide any benefit over placebo. In their study, the authors’ systematic review found conflicting evidence, with the majority of the studies that found in favour of beneficial effect having been funded by the pharmaceutical industry.

HARM: There are significant dangers to child cough and cold medicine. Data from 2011 National Poison Data System in the USA documented the following for child over the counter cough and cold medicines:

• 35,000 calls to poison control centres
• 3% of all pediatric poison control calls
• 5 pediatric deaths
• 10% of all pediatric toxicological deaths

In 2011 the Food and Drug Administration (FDA) pulled 500 cough/cold/allergy medicines off the market. The FDA sent a specifically advisory warning that OTC cough medicines should not be used in children under 2 years of age.

“FDA has completed its review of information about the safety of over-the-counter (OTC) cough and cold medicines in infants and children under 2 years of age.  FDA is recommending that these drugs not be used to treat infants and children under 2 years of age because serious and potentially life-threatening side effects can occur.”

The American Association of Family Physicians(AAFP) in 2012 recommend that these treatment not be used in children under the age of four.

“In children, there is a potential for harm and no benefits with over-the-counter cough and cold medications; therefore, they should not be used in children younger than four years.”

Question: What about honey for cough in children?

Reference: Oduwole et al. Honey for acute cough in children. Cochrane Database of Systematic Reviews 2012, Issue 3. Art. No.: CD007094. DOI: 10.1002/14651858.CD007094.pub3.22419319

• Population: Two randomized control trials of 265 children age 2 to 18 in ambulatory setting with cough from upper respiratory infection
• Intervention: Honey +/- antibiotics
• Comparison: Placeobo, cough medication or no treatment
• Outcome: Primary outcome was duration of cough and symptomatic relief. Secondary outcomes included quality of sleep for children and care givers, adverse effects and other issues.

Results: 

Authors Conclusions: “Honey may be better than ’no treatment’ and diphenhydramine in the symptomatic relief of cough but not better than dextromethorphan. There is no strong evidence for or against the use of honey.”

BEEM Commentary: Well performed systematic review. However, only two small studies were included. These suggested honey may be of benefit over no treatment. However, these two studies had high risk of bias.

Reference: Cohen et al. Effect of Honey on Nocturnal Cough and Sleep Quality: A Double-blind, Randomized, Placebo-Controlled Study Pediatrics; originally published online August 6, 2012; DOI: 10.1542/peds.2011-3075 cohen-honey-cough

• Population: 300 children age 1-5 years with upper respiratory infection
• Intervention: Three different types of honey
• Comparison: Placebo
• Outcome: Cough

Results:

Authors Conclusions: “Parents rated the honey products higher than the silan date extract for symptomatic relief of their children’s nocturnal cough and sleep difficulty due to URI. Honey may be a preferable treatment for cough and sleep difficulty associated with childhood URI.”

BEEM Bottom Line: If you have a child with a cough older than 1 year of age try a teaspoon of honey every 6 to 8 hours as needed.

BOTULISM WARNING:

Honey should not be given to children under the age of 1 year of age due to the risk of botulism.

KEENER KONTEST: Last weeks winner was Jaci Duszynski from USA. She has learned from TheSGEM that all bleeding stops…eventually:)

Be sure to listen to the podcast to hear this weeks Keener Kontest question. Email your answer to  TheSGEM@gmail.com. Use “Keener Kontest” in the subject line. First one to email me the correct answer will win a cool skeptical prize:)

Remember to be skeptical of anything you learn, even if you heard it on The Skeptics Guide to Emergency Medicine. Talk with you next week.

This is the 25th podcast of the Skeptics Guide to Emergency Medicine. Every so often I like to take a 10,000 foot view of things. In previous episodes we have looked at the top five FOAMed sites and the Choosing Wisely campaign. That reminds me, congratulations to ACEP for finally joining the Choosing Wiesely initiative to not over test and over treat our patients in the emergency department.

So back to the title of todays podcast, Who Are You? There has been lots of great feedback since launching TheSGEM in the fall of 2012. A few individuals have really helped improve the project including Drs. Chris Carpenter and Jason Wagner.

One of my biggest constructive critics has been Dr. Katrin Hruska from Sweden. She is very interested in social media and follows TheSGEM podcast.

TheSGEM wants to turn MedEd on its head. Use social media as a disruptive technology to provide the front line provider with the high quality, clinically relevant information to the patients bedside. The podcast lets TheSGEM listener turn their car into a classroom for 15-20 minutes commute. Rather than eminence based medicine from the grey hairs and no hairs trickling down to the masses TheSGEM tries to bubble it up from the grass root providers.

Much of the information for TheSGEM comes from the Best Evidence in Emergency Medicine (BEEM) project started by Dr. Andrew Worster of McMaster University. He is my evidence based medicine guru/mentor. Dr. Worster put together the BEEM Dream Team of EBM.

The social media is the message. Gen Y can teach their baby boom teachers about podcasts and twitter. Twitter must have been designed with ED doctors in mind. If you can’t get the message across in 140 characters or less we have lost interest.

The Skeptics Guide to Emergency Medicine was a revolution when it started but now has become an evolution. The hard part was getting the project started. I have adapted new technology, learned garage band and fingured out how to edit a podcast. Some things have worked well like the Keener Kontest, PUB cast in Oxford and having great guests like Dr. Tony Seupaul and medical student Lauren Westafer. Some things I have struggled with like finding the best microphone for good audio quality. I have fallen down at times, made mistakes but picked myself up to try again.

Katrin Hruska’s Questions of TheSGEM:

• Question#1: What problem is TheSGEM trying to solve?
• Question#2: After listening to TheSGEM what do you want the listener to do differently?
• Question#3: Who should not listen to TheSGEM?
• Question#4: What has TheSGEM achieved so far?
• Question#5: What is the purpose of the Keener Kontest?

KEENER KONTEST: Last weeks winner was Yifan Li from Western University. Yifan correctly identified  that SPS3 stood for: Secondary Prevention of Small Subcortical Stroke. This is the second time Yifan has won the Keener Kontest. Therefore, I am going to send a cool skeptical prize to the person who was second in getting the correct answer, Jennifer Mazerolle from Chatham-Kent Health Alliance.

Be sure to listen to the podcast to hear this weeks Keener Kontest question. Email your answer to TheSGEM@gmail.com. Use “Keener Kontest” in the subject line. First one to email me the correct answer who has not won before will win the cool skeptical prize:)

Remember to be skeptical of anything you learn, even if you heard it on The Skeptics Guide to Emergency Medicine. Talk with you next week.

Case Scenario: 68yo man arrives to the ED with 15 minutes of tingling in his right arm and leg. He has a history of hypertension and previous TIA. The examination is completely normal. He is already taking ASA 325mg OD.

Background: Stroke is a leading cause of disability. It is the third most common cause of death in the USA. Twenty-five percent of ischemic strokes are lacunar. ASA has been the accepted standard of care. Dual therapy for cardiovascular problems like ACS and stenting has shown to be of benefit in other studies (ex: CURE Trial). Clopidogrel in Unstable Angina to Prevent Recurrent Events

Question: Should you add clopidogrel to prevent a stroke for someone already taking ASA?

Reference: Benavente OR et al. Effects of clopidogrel added to aspirin in patients with recent lacunar stroke: SPS3 Trial. N Engl J Med. 2012 Aug 30;367(9):817-25.

• Population: 3020 patients from 82 centres in North America, Latin America, and Spain with recent symptomatic lacunar infarcts identified by MRI
• 

Intervention: Clopidogrel 75mg and ASA 325mg
• Comparison: Placebo and ASA 325mg
• Outcome: Recurrent stroke (ischemic or intra-cranial hemorrhage)

Results:

• NO BENEFIT (efficacy)
  • Recurrent CVA 2.5%/yr C+ASA vs. 2.7%/yr ASA (HR 0.92; 95% CI,0.72 to 1.16)
  • Recurrent ischemic CVA (HR 0.82; 95% CI, 0.63 to 1.09)
  • Disabling or fatal CVA (HR 1.06; 95% CI, 0.69 to 1.64)

• MORE HARM (bleed and death)
  • Major hemorrhage doubled 2.1%/yr C+ASA vs. 1.1%/yr ASA (HR 1.97; 95% CI, 1.41 to 2.71; P<0.001)
  • All-cause mortality increased n=113 C+ASAvs. n=77 ASA (HR 1.52; 95% CI, 1.14 to 2.04; P=0.004)

Authors Conclusions: “Among patients with recent lacunar strokes, the addition of clopidogrel to aspirin did not significantly reduce the risk of recurrent stroke and did significantly increase the risk of bleeding and death.”

BEEM Commentary: This was a large 2×2 factorial design randomized control trial. It showed adding clopidogrel to ASA did NOT reduce recurrent CVA and DID increase risk of bleed and death. The study was stopped early due to harm and lack of efficacy.

BEEM Bottom Line: The risk of adding clopidogrel to patients already on ASA for secondary CVA prevention exceeds the benefits.

KEENER KONTEST: Last weeks winner was Alain-Remi Lajeunesse from Hamilton, Ontario. He knew that the BEEM conference in Hamilton was called SteelBEEM because of its large steel industry.

Be sure to listen to the podcast to hear this weeks Keener Kontest question. Email your answer to TheSGEM@gmail.com. Use “Keener Kontest” in the subject line. First one to email me the correct answer will win a cool skeptical prize:)

Don’t Panic, there is still time to sign up for SteeleBEEM 2013 Feb 21st and 22nd in Hamilton, Ontario. Just contact Teresa.

Remember to be skeptical of anything you learn, even if you heard it on The Skeptics Guide to Emergency Medicine. Talk with you next week.

Case Scenario: 28yo woman presents to the ED at 2am with steadily increasing right lower quadrant (RLQ) pain. She has a past medical history of ovarian cysts. Her vital signs are stable, afebrile and tender over the RLQ. The blood work is unremarkable and specifically her pregnancy test is negative. Ultrasound and CT scan are not available overnight. What is your disposition and management of this patient?

Background: Undifferentiated abdominal pain is a high volume, high risk complaint. It represents approximately 7% of ED visits. Acute appendicitis is the second most common cause of malpractice litigation in children 6 – 17 years old.  Ten percent of all closed malpractice cases are due to missed diagnoses of appendicitis. It is not practical to image everyone with lower abdominal pain to rule out acute appendicitis in every case.

• Lifetime acute appendicitis incidence is 8.6% in males and 6.7% in females
• Lifetime appendectomy rates are 12% for males and 23.1% for females.
• Negative laparotomy rate is 10-20%.
• Appendectomy complications rate is 4-13%

Question: Does a bumpy car ride predict appendicitis?

Reference: F. Ashdown el al. Pain over speed bumps in diagnosis of acute appendicitis : A diagnostic accuracy study. BMJ Christmas Issue 2012

• Population: Adults >16yrs referred to on-call surgery for assessment
• 

Intervention: Speed bumps
• Comparison: Migratory pain, nausea and vomiting, and rebound tenderness
• Outcome: Sensitivity/specificity and likely hood ratios for appendicitis

Results: A total of 101 patients were included in this study. Sixty-eight reported driving over speed bumps on the way to the hospital. Four patients were excluded from the 68 (1-no histology available and 3-treated with antibiotics). Fifty four were “speed bump positive” of the 64.  The diagnosis of appendicitis was confirmed histologically in 33 or the 34 who reported worsened pain over speed bumps.  This gives a sensitivity of 97% (85% to 100%) and a specificity of 30% (15% to 49%). The positive predictive value (PPV) was 61% (47% to 74%), and the negative predictive value (NPV) was 90% (56% to 100%). The  positive likelihood ratio (LR) was 1.4 (1.1 to 1.8) and the negative LR was 0.1 (0.0 to 0.7).

Additonal Resources:

• Evidence-Based Emergency Care: Diagnostic Testing and Clinical Decision Rules. This is a great referrence book for emergency physicians and fellows training in emergency medicine. Dr. Chris Carpenter and his fellow editors explain various diagnostic tests and clinical decision instruments.
• Diagnostic testing: an emergency medicine perspective. Worster et al. CJEM 2002; 4(5).  This is an excellent article written by the founder of BEEM, Dr. Andrew Worster. It helps emergency physicians understand the statistics of diagnositic testing.

Authors Conclusions: “Presence of pain while travelling over speed bumps was associated with an increased likelihood of acute appendicitis. As a diagnostic variable, it compared favourably with other features commonly used in clinical assessment. Asking about speed bumps may contribute to clinical assessment and could be useful in telephone assessment of patients.”

BEEM Commentary:

• Anthony: Can not be generalized to a pediatric population and more pot-holes than speed bumps in Canada.
• Jo-Ann: There was referral bias in this study because patients had to be referred to surgery to be included in the study.
• Suneel: Likelihood ratios (LR) are a good way to present the results because LR are immune to prevalence of events.
• Ken: Relatively small study (n=101) but inexpensive and no delay in lab turn around time.

The Boys of the BEEM Dream Team: Ken, Suneel and Anthony

Jo-Ann Talbot

BEEM Bottom Line: Perhaps we should ask our patients if it was a bumpy ride to the ED and did the bumps hurt?

KEENER KONTEST: Yifan Li  from Western University correctly answered last weeks Keener question. Fixed-effect models assume only one true effect size. Thus, all differences in observed effects are due to sampling error. However, Random-effect models assume that your measurements draw from a random sample in a large population. Thus, the true effect varies from study to study and the variance tells us something about the large population.  The difference between them is interference. In the Fixed-effect model, you can only make inferences about your study population. In the Random-effect model, you can make inferences on the large population since you have taken random sampling into account.

Be sure to listen to the podcast to hear this weeks Keener Kontest question. Email your answer to TheSGEM@gmail.com. Use “Keener Kontest” in the subject line. First one to email me the correct answer will win a cool skeptical prize:)

Just came back from SkiBEEM 2013. We had a wonderful time and Silver Star Mountain in BC. Lots of people eager to cut the KT window to less than one year. Don’t Panic if you missed SkiBEEM. You can join us for SteeleBEEM 2013 Feb 21st and 22nd in Hamilton, Ontario.

Remember to be skeptical of anything you learn, even if you heard it on The Skeptics Guide to Emergency Medicine. Talk with you next week.

Case Scenario: 21yo presents to the ED at 8am very distraught. She reports the condom broke last night during intercourse and requests the morning after pill.

Background: Each year here are more than 40 million aborted pregnancies worldwide. Primary prevention of pregnancy is advocated with induced abortion as the back up method. The definition of emergency contraception (EC) is the use of a device or drug as an emergency measure after unprotected intercourse to prevent pregnancy. This method of preventing pregnancy only became effective in the 1960′s with the introduction of hormonal regimens. The Yuzpe method (combination of estrogen and progestogen) became the popular method in the 1970′s. This was followed by other hormone treatments including progestogen only, anti-gonadotropin (danazol) and anti-progestins (mifepristone and ulipristal acetate). A copper intrauterine device (IUD) is a non-hormonal option that can be inserted postcoital up to five days after the estimated time of ovulation. It can also be left in the uterus as a long-term contraceptive method.

• Combo estrogen/progestogen (Yuzpe)
• Progestogen only (levonorgestrel LNG/Plan B)
• Anti-gonadotropin (Danazol)
• Anti-progestins (mifepristone/Ru486 and ulipristal acetate/UPA)
• Intrauterine device (IUD)

Question: What is the best intervention for emergency contraception?

Reference: Cheng I, Che Y, Gulmezoglu AM. Interventions for emergency contraception. Cochrane Database of Systematic Reviews 2012, Issue 8.

• Population: Adult woman attending for emergency contraception after a single episode of unprotected intercourse
• 

Intervention: Several different emergency contraceptive medications
• Comparison: Placebo, no therapy, or alternative emergency contraceptive medication
• Outcome: Pregnancy, adverse events

Results: Mid or low dose Ru486 was significantly more effective than LNG in 11 trials. This was only a marginal difference when only the four high-quality studies were included (RR 0.70, 95% CI 0.49-1.01. LNG given as a single dose of 1.5mg was just as effective as the more common 0.75mg BID in three trials (RR 0.84, 95% CI 0.53-1.33). LNG was consistently better then Yuzpe method  in five trials (RR 0.54, 95% CI 0.36-0.80).  UPA as a single oral dose showed no difference compared to LNG in two trials (RR 0.63, 95% CI:0.37 – 1.07).

Some of the medications caused nausea and vomiting and others affected menses. The side effects in all the studies were minor and there were no safety concerns.

Authors Conclusions: “Intermediate-dose mifepristone (25-50 mg) was superior to LNG and Yuzpe regimens. Mifepristone low dose (< 25 mg) may be more effective than LNG (0.75 mg two doses), but this was not conclusive. UPA may be more effective than LNG. LNG proved to be more effective than the Yuzpe regimen. The copper IUD was the most effective EC method and was the only EC method to provide ongoing contraception if left in situ.”

BEEM Commentary: ”This  is a very large Cochrane systematic review and meta-analysis with excellent methodology as we can usually expect from Cochrane. This review included 100 studies with over 55,000 women. The majority of the studies were from China, but there were also some WHO multi-national studies that confirmed many of the findings.

BEEM Bottom Line: In Canada and USA if Plan A fails then Plan B (LNG) as a single dose of 1.5mg levonorgestrel.  The anti-progestins (Ru486 and UPA) are not currently available in Canada, but are apparently available in the US. The Yuzpe method is available in Canada but must be prescribed by a physician, is less effective than LNG, and therefore, should no longer be routinely used. Since the introduction of LNG in Canada, the Emergency Department visits solely for Emergency Contraception has declined dramatically, but knowledge of the agents and their effectiveness is still important for Emergency Physicians.

Case Scenario Conclusion: The young woman was provided with information on her options including EC. The effectiveness and common side effects of EC were discussed. Shared decision making took place and you provide her with levonorgestrel (Plan B).

KEENER KONTEST:

There were many Queen fans out there who got the Keener question right. Vanilla Ice sampled the song Under Pressure featuring David Bowie. The first correct answer was from Dr. Glen Armstrong from High Prairie, Alberta.

Be sure to listen to the podcast to hear this weeks Keener Kontest question. Email your answer to TheSGEM@gmail.com. Use “Keener Kontest” in the subject line. First one to email me the correct answer will win a cool skeptical prize:)

This will be posted the day before starting SkiBEEM 2013. Look forward to seeing lots of TheSGEM listeners at the conference. The BEEM Team will be cutting that KT window down to less than one year.

Don’t Panic…all bleeding stops…eventually. Remember to be skeptical of anything you learn, even if you heard it on The Skeptics Guide to Emergency Medicine. Talk with you next week.

Case Scenario: Stop, collaborate and listen. TheSGEM is back with a brand new edition. A 72yo man has witnessed arrest while watching his grandson’s hockey game. By-standard CPR is started and he shocked out of ventricular fibrillation using the automatic external defibrillator (AED). EMS arrives and finds an patient with vital signs stable but unconscious. Paramedic calls base hospital and asks if they should start cooling on-route.

Background: Two randomized control trials showed that hypothermia post cardiac arrest resuscitation was neuroprotective. One trial (n=273) in NEJM 2002 used cooled air mattress to demonstrate good outcome at 6 months (55% vs. 39%). The smaller Australian study (n=77) also published in NEJM 2002 showed good neurologic outcome at time of hospital discharge (49% vs. 26%).

Dr. David Newman has calculated the NNT=6 for mild therapeutic hypothermia for neuroprotection following cardiopulmonary resuscitation. The Cochrane Collaboration updated their review on hypothermia for neurporotection in adults after CPR in 2012. They concluded:

• “Conventional cooling methods to induce mild therapeutic hypothermia seem to improve survival and neurologic outcome after cardiac arrest. Our review supports the current best medical practice as recommended by the International Resuscitation Guidelines.”

Question: Does pre-hospital therapeutic hypothermia improve patient outcomes after successful resuscitation?

Reference: Bernard SA et al. Induction of therapeutic hypothermia by paramedics after resuscitation from out-of-hospital ventricular fibrillation cardiac arrest: a randomized controlled trial, Circulation. 2010;122:737-742

• Population: Adults (n=234) with out-of-hospital cardiac arrest with an initial rhythm of ventricular fibrillation
• Intervention: Prehospital rapid infusion of 2L of ice-cold lactated Ringer’s
• Control: Cooling after hospital admission
• Outcome: Functional status at hospital discharge. Patients who were discharged directly home or to a rehab facility were considered to have a favorable outcome. Patients who died or were discharged to a long-term nursing facility, either conscious or unconscious, were considered unfavorable outcome.
• Exclusion criteria: Not intubated, previously depended on others for activities of daily living before the cardiac arrest, already hypothermic (< 34 degrees Celsius), or pregnant women.

Results:

Patients allocated to paramedic cooling received a median of almost 2L (1900ml). The mean decrease in core temperature was 0.8 degrees C (P=0.01).

• 47.5% paramedic-cooled patients had a favorable outcome at hospital discharge compared vs. 52.6% in the hospital-cooled group (risk ratio 0.90, 95% confidence interval 0.70 to 1.17, P=0.43).

Authors Conclusions: “In adults who have been resuscitated from out-of-hospital cardiac arrest with an initial cardiac rhythm of ventricular fibrillation, paramedic cooling with a rapid infusion of large-volume, ice-cold intravenous fluid decreased core temperature at hospital arrival but was not shown to improve outcome at hospital discharge compared with cooling commenced in the hospital.”

Ice, Ice Baby

BEEM Commentary: “There has been a great deal of interest in cooling patients after out of hospital cardiac arrest in the last decade. Some laboratory studies suggest that sooner is better. Therefore, the hypothesis was generated that perhaps prehospital cooling by paramedics would improve outcome. This study stopped prematurely. The sample size calculated to dectect a change in favourable outcome from 45%  to 60% required a sample size of 372 pateints to achieve 80% power at an Type I (alpha) error of 0.005. A planned interim analysis after 200 patients noted no difference in primary outcome and was extremely unlikely that a difference would be found between the two groups. Although the results of the present trial do not support the pre-hospital use of hypothermia, caveats to the interpretation include the short EMS transport times (may not apply to rural setting where time-to-hospital can be protracted) and premature study closure. In addition, future investigations should assess treatment started during CPR since prior to return of spontaneous circulation, all subjects had received 1L of non-cooled IVF.”

BEEM Bottom Line: Scoop and run no cooling required in the field.

Case Scenario Conclusion: Patient was not cooled in the field but on arrival. He was admitted and one week later he was the 1 in 6 person to walk out the ICU neurologically intact.

KEENER KONTEST:

There was no winner to last week’s Keener Kontest. The question was who should NOT get the flu shot according to the CDC.

Listen to the podcast to hear this weeks Keener Kontest question. Email your answer to TheSGEM@gmail.com. Use “Keener Kontest” in the subject line. First one to email me the correct answer will win a cool skeptical prize:)

Last chance to sign up for SkiBEEM 2013 Feb 4-6 at SilverStar BC. This is the Best Evidence in Emergency Medicine (BEEM) conference. It presents the critical reviews of practice changing EM literature from the year. Attending SkiBEEM can cut your knowledge translation window to less than 1 year. Come and participate in a live episode of TheSGEM as a PUBcast at the conference!

Don’t Panic…all bleeding stops…eventually. Word to your mother. Remember to be skeptical of anything you learn, even if you heard it on The Skeptics Guide to Emergency Medicine. Talk with you next week.

Immunize: The Vaccine Anthem

I really wanna immunize so frickin’ bad
Protect you from those germs you’ve never had
Don’t want you to catch the mumps–meningitis too
Pertussis, hepatitis or the flu.

But everywhere I turn my eyes,
The internet is spreading lies.
So many parents scared by fairy tales and hate
I need to educate, so that I can vaccinate

Yo, lots of parents scared by the myths, they’re
Peeing in their underwear
“Shots ain’t needed,” suckers scoff
Now their kids get whooping cough
This bozo Wakefield said “shots make you autistic”
But that fool was paid by lawyers just to jack the statistics
And now the public’s understanding’s unrealistic
These lies on the internet make me go ballistic
Like aluminum in vaccinations, folks say, “Oh No”
But you get more in your diet just from eating some Ho Hos
Suckaz think, they catchin’ Flu from the Flu shot
But the shot stops flu, and that’s a cold that you caught, fool
Keep sayin’ that vaccine and not disease makes you illest
Like Gary Coleman said, “Whachu talkin’ ‘bout, Willis?”

But everywhere I turn my eyes,
Some so-called expert’s spreading lies
A different talk show every night, oh why get played
Cause it would be so great, if we’d all just vaccinate

oh oooh oh oooh we should all just vaccinate
oh oooh oh oooh we should all just vaccinate

Patients ask me what I’d do for my relatives
Knowin’ lots of medicine
I’d show ‘em vaccinations save more lives than almost anything
Don’t let my daughter get up in the car without a car seat
Why should I let her get pertussis, measles, or the mumps, G?
These ain’t the kinda shots that killed Tupac
They put the brakes on polio so little kids could walk
Prevented deafness, retardation–changed the world
You’re damn right I’m gonna give ‘em to my little girl
Don’t give Chuck Norris shots, though, that’d be dim
Chuck need vaccines? Naw…vaccines need him
To beat some sense up in you, do what needs to be done
To keep our children in the playground, not up in no iron lung

Sing it

I really wanna immunize so frickin’ bad
Protect you from those germs you’ve never had
Don’t want you to catch the pox–rotavirus too
Polio, rubella or H flu.
But everywhere I turn my eyes
Some B-list actor’s spreading lies
Listen to reason, hear the truth ‘fore it’s too late
We can keep our children safe, if we’d all just vaccinate

oh oooh oh oooh we should all just vaccinate
oh oooh oh oooh

I really wanna immunize so frickin’ bad

Canadian Stats

USA Flu Stats

Question #1: Does the flu shot work in the general public?

KEENER KONTEST:

Last weeks winner was James Yan who is studying medicine in London, Ontario. He correctly defined the difference between a greenstick and buckle fracture. “A greenstick fracture is a fracture on young, softer bone, that bends/warps before cracking/breaking on one side (like a young, supple branch – hence the name, immature bone is less rigid). A buckle or torus fracture is one in which part of the bone bends in and compresses in on itself (buckles) without breaking..”

Listen to the podcast to hear this weeks Keener Kontest question.

Email your answer to TheSGEM@gmail.com. Use “Keener Kontest” in the subject line. First one to email me the correct answer will win a cool skeptical prize:)

It is NOT too late to cut your KT window less than 1 year. Get in contact with Teresa ASAP and sign up for SkiBEEM 2013 Feb 4-6 at SilverStar BC. You will have a jump start on the content for up coming TheSGEM podcasts.

Don’t Panic…all bleeding stops…eventually. Remember to be skeptical of anything you learn, even if you heard it on The Skeptics Guide to Emergency Medicine. Talk with you next week.

A collection of Rick’s Rants can be viewed on YouTube or read about in his new book called: A Nation Worth Ranting About: Rick Mercer Report From Across Canada.

It’s The Most Wonderful Time of the Year:

Well the malls are packed; the bells are jingling. It’s that wonderful time of year when Canadians from all walks of life prepare to experience the miracle of flu season. Not a lot of talk of the flu this year. We only get freaked out when it’s named after a pig or a chicken. Yet every year the old fashion no-name flu kills a whack of Canadians – basically the population of Flin Flon. Good town.

And the best defence, better than washing your hands or even avoiding that moron who comes to work sick and then coughs on your neck in the elevator, is the flu shot. In my office we gave it away for free. I stood there and said, “Okay folks, free flu shot, who’s in?” Two out of ten people made a move – two out of ten. If I had said there was free smoked meat sandwiches at the end of the hall there would have been a stampede.

Don’t be one, get one.

Turns out a lot people won’t get the flu shot on principle. Why? Well, “I haven’t had the flu in years, why would I get a flu shot?” said one. Good point. I have never been run over by a car so why would I look both ways? Or, and this is my favourite, when someone looks at you very seriously and says, “Did you know there’s dead flu virus in the flu vaccine?” Yes, I am aware of that. It’s why it’s called a vaccine. It’s why we don’t all have polio. I have one friend who refuses any vaccines at all based on something he read on the internet. But to be fair, he still smokes Export A in the green package, so he’s basically a medical doctor.

Look, I get lazy. I’m lazy. I get afraid of needles, but even if you are healthy enough to fight the flu, if you get the flu chances are you could pass it on to someone who can’t fight it. So come on Canada, roll up your sleeve. It’s just a little prick. Don’t be one, get one.

I am not sure why iTunes does not show them any more? I have contacted them and trying to work it out. You can still find all the old podcasts on TheSGEM website attached to their blog entries. However, people like to subscribe to iTunes and have automatic access.So in classic emergency medicine style I came up with a back up solution. All the previous podcasts are now attached to this blog entry and hopefully Word Press uploads them to iTunes…

• SGEM#1: Welcome to the SGEM
• SGEM#2: History of EBM
• SGEM#3: Ottawa Ankle Rules
• SGEM#4: Getting Un-Stoned
• SGEM#5: Ottawa Knee Rules
• SGEM#6: PUBcast from Oxford
• SGEM#7: Every Breath You Take
• SGEM#8: ABCD2 Not as Simple as 1,2,3
• SGEM#9: Who Let the Dogs Out
• SGEM#10: Ten Commandments of EBM
• SGEM#11: All Seizures Stop…Eventually
• SGEM#12: Oh Dance-a-tron
• SGEM#13: Better Out than In

Remember that all bleeding stops…eventually and be skeptical of anything you are taught, even if you are taught it on The Skeptics Guide to Emergency Medicine.

Now Dr. Carpenter has a book published with Drs. Jesse Pines, Ali S. Raja, and Jeremiah D. Schuur. It is called Evidence-Based Emergency Care: Diagnostic Testing and Clinical Decision Rules, 2nd Edition. We have added it to The Skeptics Guide to Emergency Medicine Book Club. Yes, TheSGEM does have a Book Club. Look under additional resources on TheSGEM home page and scroll down to Books.

Dr. Chris Carpenter

This book fits in well with the EBM philosophy of TheSGEM, its goal of cutting the knowledge translation window down to less than 1 year, plugging some leaks in the Pathman Leaky Pipe model and encouraging doctors to choose wisely.

Ever been in a room full of people and wonder who is the smartest guy in the room? I have had that feeling many different times. When it comes to EBM and diagnostic testing, if Dr. Carpenter (aka Capt. Cranium) is in the room he IS that guy.

If you have any other books you have enjoyed, changed your practice or want to share just send me your suggestion to TheSGEM@gmail.com

Buckle Fracture

Fractures of the distal radius are the most common fractures in childhood (Landin et al). There is a difference between buckle fracture and greenstick fractures.

Buckle fractures (also called torus) are defined as a compression of the bony cortex on one side with the opposite cortex remains intact. In contrast, a greenstick fracture the opposite cortex is not intact.

Greenstick Fracutre

There seems to be a variety of approaches to the treatment of buckle fractures(cast vs. splint and lenght of immobilization). A survey done over a decade ago in Canada demonstrated this variablity (Plint et al 2003). There is even an apparent devide between North America (favour casting) (Plint et al 2004) vs. Europe (favour splinting) (Plint et al 2006).

Question: Cast vs. Splint for Buckle Fracture and appropriate follow-up?

As with most evidence based medicine (EBM) it can be a little messy.  As my mentor, Dr. Andrew Worster from McMaster always says…the EBM answer is always “it depends”.

Looking back through the literature without commenting on every single article on the subject here are some highlights. I want to mention these before the critical review of two more recent articles on the subject.

Why discuss such old data from nine years ago? As SGEM listeners know it takes an average of 10 years for high quality, clinically relevant inforamtion to reach the patients bedside. This case was an excellent opportunity to address this knowledge translation problem.

The father of the patient told me the doctor at the peds emerg said splinting would be OK but they were going to put a full cast on anyways. This is one of the key leaks in the Pathman pipeway. The academic centre was AWARE of the evidence but did they ACCEPT, AGREE, able to ACT upon or ADHERE to the evidence?

Plint et al (2004) mentioned earlier published a retrospective chart review of 309 children with buckle fractures of the distal radius or ulna. The average age was 9 years old. They found no benefit to casting vs. splinting.

• None needed a reduction
• None needed orthopedic intervention
• No displacement of their fracture

Potential harm:

• Orthopedic visits (time for parents and child)
• Repeat xray
• 12% in casted group had subsequent ED visit for cast problems

There are limitations to a retrospective study being conducted at a single site. In addition, 11% of patient were lost to follow-up. With these limitations the authors concluded “Orthopedic follow-up visits and radiographic follow-up may have minimal utility in the treatment of pediatric wrist buckle fractures. ED casting may pose more risk than benefit for these children. Splinting in the ED with primary care follow-up appears to be a reasonable management strategy for these fractures. A prospective study comparing ED splinting and casting for pediatric wrist buckle fractures is needed”.  

Plint et al rose to the challenge of a prospective trial in 2006. They published a RCT of removable splinting vs. casting for wrist buckle fractures in children. This study had n=87 with average age 9 years old.  They used a self-reported outcome tool called Activities Scales for Kids performance version (ASKp). The main outcome was the ASKp score at 14d post injury which favoured splinting over casting.

Results:

• No difference in pain
• Better function with splint
• Less difficulty with daily activities (ex. bathing/showering)
• Return to sports sooner

There were some significant limitations to this study. They could not blind researchers to parts of the ASKp tool, there was high loss to follow-up and no intention to treat analysis. The authors conclusions were ” Children treated with removable splinting have a better physical functioning and less difficulty with activities than those treated with a cast.”

Now let us jump ahead to some more recent literature. These two studies look at greenstick fractures and/or transverse fractures of the distal radius that are minimally displaced. Buckle fractures were specifically excluded from these two studies. Therefore, these studies represent more serious fractures and risk of complications.

Reference: Kropman et al . Threatment of impacted greenstick forearm fractures in children using bandage or cast therapy a prospective randomized trial. J Trauma 2010

• Population: Children 4-13y presenting to ED with impacted greenstick fractures of the distal 1/3 of radius or ulna
• Intervention: Soft bandage wrapping treatment (BT) for 4 weeks
• Control: Below elbow backslab cast for 1 week followed by circumferential cast treatment (CT) for 3 weeks
• Outcome: 1) Pain, 2) Discomfort, 3) Function, 4) Fracture displacement

Results:

1. Pain: more in first week only of BT group
2. Discomfort: no difference in use of pain killers and less itching in BT group
3. Function: quicker return to normal function with BT
4. Fracture Displacemet: No difference in secondary angulation and no refractures in either group

Authors Conclusions: “BT for impacted greenstick fractures of the distal forearm is a safe technique, patients treated with bandage suffer greater pain at the start of the treatment, are able to return to normal activities sooner, and have less discomfort when compared with the standard CT.”

BEEM Commentary: This is a well-conducted randomized trial. The patients are genearlizable to the population presenting to the ED and the oucome measures are clinically relevant. The sample size is moderate (n=90)

BEEM Bottom Line: As long as parents are aware that BT is associated with increased pain in the first week post-injury, this is a safe alternative to traditional casting. Patients will be more likely to return to normal function faster and experience less itching.

Reference: Boutis et al. Cast vs. Splint in Children with Minimally Angulated Fractures of the Distal Radius: A Randomized Control Trial. CMAJ 2010

• Population: Convenient sample of children age 5-12 yrs presenting to ED with minimally angulated/displaced greenstick or transverse fractures of the distal radius (EXLUDED buckle/growth plate or open fractures)
• Intervention: Prefabricated wrist splint worn for 4 weeks
• Control: Short arm fibreglass cast worn for 4 weeks
• Outcome: Primary: physical function at 6 weeks using (ASK), Secondary: fracture angulation, pain, use of splint, grip strength, patient preference

Results:

1. Primary: No difference in ASK score at 6 weeks mean 1.44 (95% CI -1.75 to 4.62)
2. Secondary: No difference in fracture angulation, pain, grip strength BUT patient and parental preference was for a splint

Authors Conclusions: “In children with minimally angulated greenstick or transverse fractures of the distal radius, use of a prefabricated splint was as effective as a short arm cast with respect to recovery of physical function. In addition, the devices did not differ significantly with regard to the maintenance of fracture stability and the occurrence of complications, and the splint was superior to the cast in terms of parental and patient satisfaction and preferences.”

BEEM Commentary: This is a well conducted randomized trial of 96 children. The methodology was sound and the follow-up was excellent. The researchers focused on clinically-relevant outcomes and there was no significant differences found between the cast group and the splint group. This is the first study examining this research question and further studies will help solidify these conclusions.

BEEM Bottom Line: Splinting appears to be a viable option for minimally angulated/displaced fractures of the distal forearm in children.

Further Reading:

1. Ransborg and Siversten. Distal radius fractues in children: substantial difference in stability between buckle and greenstick fractures. Acta Orthopaedica 2009. They concluded that buckle fractures are stable, do not requrie follow-up and 6/207 had mild complication because of plaster casting.
2. Abraham et al. Interventions for treating wrist fractures in children. Cochrane 2008

Case Scenario Conclusion: A discussion was held with the father about his 9 year old ringette star. Risks and benefits of casting vs. splinting/BT was reviewed. A shared decision was made to remove the cast and go with a splint. He also prefered following up with his local primary care physician in 2 weeks rather than driving 1hr to the pediatric orthopedic fracture clinic. The patient did well and is back on her team with full function.

KEENER KONTEST:

Last weeks winner was Daniel Beamish who is studying medicine in Australia. He correctly identified GMEP as the Global Medical Education Project. Defined by its founder Dr. Mike Codogan as the “The Facebook of medicine. A place to share medical videos, discussion, questions and conversation without feeling über nerdy.” If you have not joined this FOAMed movement then what are you waiting for?

Listen to the podcast to hear this weeks Keener Kontest question.

Email your answer to TheSGEM@gmail.com. Use “Keener Kontest” in the subject line. First one to email me the correct answer will win a cool skeptical prize:)

OK all you procrastinators, time is running out to sign up for take advantage of SkiBEEM 2013 Feb 4-6 at SilverStar BC.  You want the most current EBM reviews from 2012 then email Teresa. Cut your KT window to less than 1 year. We are even planning on even doing a live episode of TheSGEM as a PUBcast at the conference!

Don’t Panic…all bleeding stops…eventually. Remember to be skeptical of anything you learn, even if you heard it on The Skeptics Guide to Emergency Medicine. Talk with you next week.

Mike is an emergency physician from Australia who has a passion for social media, medical education and medical informatics. Mike started the blog Life in the FastLane  to promote emergency medicine and critical care education at undergraduate and postgraduate training level. Outside of medicine, he is a writer, father and ephemeral disambiguant (I don’t know what this means either).

While Dr. Joe Lex could be considered the father of FOAM (Free Open Access to Meducation) because of his 2,100 Free Emergency Medicine Talks, Mike Cadogan is the Rock STAR!

I encourage everyone to log onto the GMEP site, register, explore, contribute and learn.

Remember to be skeptical of anything you learn, even if you learned it on GMEP.

Background on Traumatic Hyphema: Hyphemas are defined as blood in the anterior chamber (between the cornea and iris). It often results from a blow/direct trauma to the eye. Young men suffer from this condition in a 3:1 ratio compared with women. Sports injuries were responsible for 60% of cases. Traumatic hyphemas rarely result in permanent vision loss and resolve without any treatment. Antifibrinolytics have been tried either orally or topically applied to try and prevent vision loss.

Question: What should be done for a traumatic hyphema in the Emergency Department?

Reference: Gharaibeh  A. et al.  Cochrane  Database of Systematic Reviews 2011, Issue 1. Art.  No.:  CD005431.  DOI:10.1002/14651858.CD005431.pub2.

• Population: 19 randomized and 7 quasi­randomized studies (n=2,560) with traumatic  hyphemas.
• Intervention: Both Medical and Non­Medical
• Control: Placebo, standard care or observation
• Outcome: Primary: VA time of resolution. Secondary outcome: risk of and time to rebleed, risk of corneal bloodstaining, risk of peripheral anterior synechia, risk of pathological increase in IOP and risk of optic atrophy development.

Results:

1. Primary: No change in primary end point – Time to best VA or Final VA following hyphema?
2. Secondary: Antifibrinolytics reduce the risk of secondary bleeding, hyphema took longer to resolve but VA in the end was not different.

Authors Conclusions: “Traumatic hyphema in the absence of other intraocular injuries, uncommonly leads to permanent loss of vision. Complications resulting from secondary hemorrhage could lead to permanent impairment of vision, especially in patients with sickle cell trait/disease.We found no evidence to show an effect on visual acuity by any of the interventions evaluated in this review. Although evidence is limited, it appears that patients with traumatic hyphema who receive aminocaproic acid or tranexamic acid are less likely to experience secondary hemorrhaging. However, hyphema in patients on aminocaproic acid take longer to clear.”

Canadian Content: This comes from a Canadian Beer ad from a few years ago. It is something to visually explain the pulling of the jersey over the other guys head before a fight…very hockey night in Canada-ish. Just click on the picture and enjoy.

BEEM Commentary: Trauma to the eye can lead to blood in the anterior chamber. The hyphema is typically a self-limiting condition and is rare to cause permanent vision loss. Many medical treatments have been tried to improve visual outcome and speed up resolution. The most common topical or oral medical is the antifibrinolytics (tranexamic acid or aminocaproic acid) despite being controversial. Many other modalities have also been tried with variable effect (steroids, cycloplegics and ASA). Non-medical treatment has also been tried. These included patching of the eye, bed rest, elevation of the head, and admission to hospital. This Cochrane review is typical of systematic reviews coming out of this collaborative. They searched lots and lots of papers, found few to include and the quality was limited. No intervention made a positive impact on the primary outcome. Despite the negative results they were able to produce a 145 page review that said nothing impacts the primary outcome and highlight that the secondary outcome of less re-bleeds took place on antibibrinolytics but were poorly tolerated.

BEEM Bottom Line: Most patients with isolated traumatic hyphema do well. Nothing seems to effect visual acuity. There may be a benefit with antibrinolytic agents to prevent re-bleeds but delays resolution of primary bleed and has side effects. There is also no evidence for non-medical interventions. The ED management of traumatic hypemas would be to prescribe nothing and call ophthalmology.

Case Scenario Conclusion: This young man who was out for a night of quiet conversation and drinks and was “doing nothing” was refered to ophthalmology. He did not keep his outpatient appointment. You know this because he re-presented to the ED three months later with his hyphema resolved with no visual complications. However, he now has a painful swollen fifth MCP of his right dominant hand and you suspect a boxer fracture.

KEENER KONTEST:

Last weeks winner was Allison Clark from Washington University in St. Louis. She is a second year ED resident and correctly identified that funnel plot are used to check for bias in systematic reviews/meta analyses. She had just learned this from the WashU ED Journal Club which was my #1 pick in the top FOAMed sites of 2012.

Listen to the podcast to hear this weeks Keener Kontest question.

Email your answer to TheSGEM@gmail.com. Use “Keener Kontest” in the subject line. First one to email me the correct answer will win a cool skeptical prize:)

It is now 2013 and time to take advantage of SkiBEEM 2013 Feb 4-6 at SilverStar BC.  We will be presenting all the latest/greatest EBM reviews. This can cut your knowledge translation window to less than 1 year. We are even planning on even doing a live episode of TheSGEM as a PUBcast at the conference!

Don’t Panic…all bleeding stops…eventually. Remember to be skeptical of anything you learn, even if you heard it on The Skeptics Guide to Emergency Medicine. Talk with you next week.

I hope you enjoy these music videos. Watch this Sunday for a new Skeptics Guide to Emergency Medicine podcast called Eye of the Tiger.

Background on Upper GI Bleeds: Here is the usual blurb about and the problem…it’s common, it effects millions of patients every year, deadly and it’s expensive. The details:

• Upper GI bleed the most common reason for ER admit with lots of morbidity and mortality (Gilbert 1990; Longstreth 1997)
• Usually a result of peptic ulcer (Laine 1994; Silverstein 1981)
• Prevalence 170/100,00 adults each year (Blatchford 1997)
• Cost $750 million/yr in USA and utilizes lots of resources  (Gralnek 1998; Gralnek 1997; Lee 1999; Longstreth 1995).

Question: Does the use of PPIs prior to endoscopy in acute upper GI bleeds change patient oriented outcomes?

Reference: Sreedharan A et al. Proton pump inhibitor treatment initiated prior to endoscopic diagnosis in upper gastrointestinal bleeding. Cochrane Database Syst Rev. 2010 Jul 7;7:CD005415. Review. PubMed PMID: 20614440.

• Populations: 2223 participants in six RCTs
• Intervention:  PPI (oral or IV)
• Control: placebo, H2 blocker or no treatment prior to endoscopy
• Outcome: 

1. Primary outcome was all cause mortality within 30 days after the acute bleed.
2. Secondary outcomes:

• Rebleeding within 30 days
• Surgery for continued or recurrent bleeding within 30 days
• LOS in hospital
• Transfusion requirements
• Proportion of participants with high-risk stigmata at the time of endoscopy
• Proportion of participants receiving endoscopic treatment at index endoscopy

Results:

1. Primary: Mortality six trials n=2223 NO DIFFERENCE

• Rebleeding five trials n=2,121 NO DIFFERENCE
• Surgery five trials n=2,165 NO DIFFERENCE
• LOS – could not be analyzed
• Trasfusion – could not be analyzed
• SRH four trials n=1,332 37.2% PPI vs. 46.5% placebo (OR 0.67; 95% CI 0.54 TO 0.84) did not stand up to sensitivity analysis and fixed effect vs. random effect model
• Active bleed at scope four trials n=1,332 8.6% PPI vs. 11.7% placebo (OR 0.68; 95% CI 0.50 to 0.93)

Authors Conclusions: “PPI treatment initiated before endoscopy for upper gastrointestinal bleeding might reduce the proportion of participants with SRH at index endoscopy and significantly reduces requirement for endoscopic therapy during index endoscopy. However, there is no evidence that PPI treatment affects clinically important outcomes, namely mortality, rebleeding or need for surgery.”

BEEM Comments: People who present to the ED with GI bleeds are usually undifferentiated. We do not know for sure the cause of the bleeding. Applying a costly treatment that does not seem to positively effect clinically important end points like mortality, need for surgery or re-bleeding does not seem wise.  Proton pump inhibitors may be required but this data does not support the routine use of them before endoscopy.

BEEM Bottom Line: Routine use of proton pump inhibitors is not required in the emergency department setting for acute upper GI bleeds.

More Information: The oldest study in this systematic review was by Daneshment et al published in the BMJ in 1992. It had 1147 patients and found no difference comparing PPIs and control in mortality, rebleeding rates or requirement for surgery.  They did find a significant difference between endoscopic stigmata of hemorrhage in patients treated with PPIs.

David Newman did a great in depth review of this topic on SmartEM podcast. You can also find a good summary of this information on his website TheNNT

Case Scenario Conclusion: Jolly old St. Nick was stabilized in the emergency department. He went for endoscopy where the GI docs gave him a pre-scope dose of IV PPI anyways. He did well and was told to make some lifestyle changes.

KEENER KONTEST:

Last weeks winner was Caroline Burge from Caboolture Hospital, Queensland, Australia. She correctly knew that Dr. Henry Jones Jr. got his nickname “Indiana” from the family dog.

Listen to the podcast to hear this weeks Keener Kontest question.

Email your answer to TheSGEM@gmail.com or go to the “Contact Us” link at the top of the home page. Use “Keener Kontest” in the subject line. First one to email me the correct answer will win a cool skeptical prize:)

If you want to cut the KT window down to less than 1 year consider coming to SkiBEEM 2013 Feb 4-6 at SilverStar BC.  Contact Teresa early in the new year to secure your spot at the BEST emergency EBM conference.

Happy holidays and we will be back next week with one final show for 2012. Stay tuned because we have a very special guest lined up for this episode.

The American Board of Internal Medicine (ABIM) started the project called Choosing Wisely. According to the ABIM foundation website: “Choosing Wisely is part of a multi-year effort of the ABIM Foundation to help physicians be better stewards of finite health care resources. Originally conceived and piloted by the National Physicians Alliance through a Putting the Charter into Practice grant, nine medical specialty organizations, along with Consumer Reports, have identified five tests or procedures commonly used in their field, whose necessity should be questioned and discussed. The resulting “Five Things Physicians and Patients Should Question” will spark discussion about the need—or lack thereof—for many frequently ordered tests or treatments.”

Choosing Wisely partners include:

• American Academy of Allergy, Asthma & Immunology
• American Academy of Family Physicians
• American College of Cardiology
• American College of Physicians
• American College of Radiology
• American Gastroenterological Association
• American Society of Clinical Oncology
• American Society of Nephrology
• American Society of Nuclear Cardiology
• National Physicians Alliance

Keener Kontest: You need to listen to the show this week to find out the question. Email your answer to TheSGEM@gmail.com or go to the “Contact Us” link at the top of the home page. Use “Keener Kontest” in the subject line. First one to email me the correct answer will win a cool skeptical prize:)

If you do not choose wisely we might end up like this guy in the Indiana Jones Movie “he chose…poorly”. We want to choose wisely and cut the KT window to < 1 year by registering for SkiBEEM 2013 Feb 4-6 at SilverStar BC.

Enjoy time spent with friends and family.

Watch the BEEM faculty elves dance around in this YouTube video. If you want to see more of the BEEM group consider coming to SkiBEEM 2013.

Background on Dehydration in Children:

Dehydration in children is a common presentation to the emergency department. A main cause of dehydration in this age group is gastroenteritis which is charaterized by acute onset diarrhea with or without nausea, vomiting, fever and abdominal pain. The scope of the problem was quantified by Glass in 1991. This study showed the following:

• 20-40 million episodes of diarrhea in children each year in the USA
• resulting in 2-4 million physician visits per year
• 10% of all hospital admissions of children < 5 yrs old

Goldman et al Pediatrics in 2008 published a helpful table describing the degree of dehydration in children ranging from mild, moderate to severe.

Most cases of gastroenteritis are mild , self-limiting and can be treated effectively with oral rehydration. For more information on visit this site on Oral Rehydration Therapy. The Canadian Pediatric Society also has a algorithm for oral rehydration (see below).

Question: What can we use to prevent vomiting/IV fluids/admissions in children with gastroenteritis?

Reference: DeCamp LR et al. Use of antiemetic agents in acute gastroenteritis: A systematic review and meta-analysis. Arch Pediatr Adolesc Med. 2008 Sep;162(9):858-65

Populations: Children with vomiting from gastroenteritis.    

Intervention:  Antiemetic medications    

Control: Placebo

Outcome: Further vomiting, requirement of intravenous fluids (IVF), admission to hospital, return to ED, episodes of diarrhea.

Results:

There were 11 articles that met the inclusion criteria: ondansetron (n = 6), domperidone (n = 2), trimethobenzamide (n = 2), pyrilamine-pentobarbital (n = 2), metoclopramide (n = 2), dexamethasone (n = 1), and promethazine (n = 1). A meta-analysis of 6 randomized, double-masked, placebo-controlled trials of ondansetron was performed.

• Prevent admission NNT=14 (95% CI 9-44)
• Prevent IVF NNT=5 (95% CI 4-8)
• Prevent further emesis NNT=5 (95%CI 4-7)

Authors Conclusions:

“Ondansetron is the only antiemetic agent with consistent, proven efficacy in reducing vomiting from gastroenteritis. Other antiemetic drugs have not demonstrated consistent effectiveness and, therefore, should not be used. In addition, moderately ill children presenting to the ED who were treated with ondansetron have a decreased risk of receiving IVF and a decreased need for immediate hospital admission.”

BEEM Comments:

Ondansetron, given orally, is an effective anti-emetic in children experiencing vomiting secondary to gastroenteritis. Doses should be given as needed for vomiting and regular dosing (i.e. every eight hours) of ondansetron should be avoided to prevent worsening diarrhea and return to ER visits.

EBM Information:

Search strategies are always important in systematic reviews. You want researchers to cast a wide net and be exhaustive in their efforts. This study did do an extensive search but there was a significant weakness. They limited the strategy to identify only english language studies. Whether or not this had an impact on the results and conclusions are unknow.

Cochrane traditionally does and excellent job in searching for articles to include. These researchers usually check everything including hand searches of medical meetings and phone calls to experts who have published in the area.

While the english language restriction is a limitation to this 2008 publication there have been other systematic reviews which agree with the conclusions of this study. These include a Cochrane review from 2011 and a BMJ update from the same authors in 2012.

If you want to cut the KT window down to less than 1 year consider coming to SkiBEEM 2013 Feb 4-6 at SilverStar BC.  Dr. Anthony Crocco our Peds BEEM guru will be updating the topic of gastroenteritis in children.

BEEM Bottom Line:

Ondansetron is an effective anti-emetic preventing further vomiting, IVF and admissions for children with gastroenteritis.

Case Scenario Conclusion:

The 4yr old was given 0.1mg/kg of ondansetron orally. They were observed for one hour with a trial of oral rehydration therapy. There was no further vomiting.

For more information about dosing, which is typically between 0.1-0.15mg/kg, check out the Ondansetron dosing in pediatric gastroenteritis: a prospective cohort, dose-response study by Freedman et al 2010 in the journal of Paediatric Drugs.

KEENER KONTEST:

Last weeks winner was Alex Zozula a medical student from Washington University in St. Louis. He correctly identified the Hitch Hiker’s Guide to the Galaxy coined the phrase “Don’t Panic”. He even knew that the second rule was “bring a towel”. Which is also good advice for emergency medicine…once the bleeding stops.

What is the NNT with ondansetron to prevent further vomiting in children?

Email your answer to TheSGEM@gmail.com or go to the “Contact Us” link at the top of the home page. Use “Keener Kontest” in the subject line. First one to email me the correct answer will win a cool skeptical prize:)

Happy Thanksgiving to all the American SGEM listeners. Check out the YouTube Video celebrating this holiday.

LITFL is a medical blog and website dedicated to providing online emergency medicine and critical care insights and education for everyone, everywhere… usually with a healthy dose of UCEM good humour, and always with endless enthusiasm.

Our Team, headed by Mike & Chris, consists (mostly) of emergency physicians and intensivists based in Australia and New Zealand.

LITFL is free and open to all — we invite you to use our content in anyway to help others learn, all we ask is that you spread the word about the FOAM (Free Open Access Meducation) revolution… Go get #FOAMed !

Case Scenario:

A healthy 23 year old woman presents 37 weeks pregnant seizing. She has no history of seizures, drugs, trauma, illness, etc.  You are addressing the A, B, Cs and the nurses asks “what med do you want to stop the seizure”?

• Ativan 2mg IV
• Diazepam 10mg IV
• Phenytoin 20mg/kg IV
• MgSO4 4g IV
• Hide in Bathroom

• visual scintillations and scotomata (occipital cortical ischemia)
• presistent headaches (cerebral ischemia or edema)
• right upper quadrand pain (capsular irritation secondary to hepatic necrosis and/or hematoma)
• shortness of breath or chest pain (secondary to non-cardigenic pulmanary edema)

While pre-eclampsia is fairly common, eclampsia is a fairly rare complications. Interestingly, only 20% of women with eclampsia have documented HTN in the week before their seizure, 10% will only have proteinuria and 10% will have neither. Eclampsia typically occurs in the second half of pregnancy or during labor. However, it can still occur after the birth.

The prevention and treatment of pregnancy induced HTN and pre-eclampsia are beyond the scope of this podcast. For more information please visit the Society of Obstetricians and Gynecologists of Canada (SOGC) Guidelines on the topic: Diagnosis, Evaluation and Management of the Hypertension Disorders of Pregnancy.

Reference:

• Population: Seven trials in low-to middle  income countries with 1386 women with  eclampsia.
• Intervention:  MgSO4 4g IV  loading dose followed by 1g/hr infusion vs.  diazepam 40mg IV loading dose followed by an  infusion of 20mg/500ml titrating to effect.
• Analyses: Death, recurrence of seizures, stroke  or any serious morbidity

Authors Conclusions:

“Magnesium sulphate for women with eclampsia reduces the risk ratio of maternal death and of recurrence of seizures, compared with diazepam.”

BEEM Comments:

BEEM Bottom Line:

Delivery of the baby is the only definitive treatment for pre-eclampsia or eclampsia. However, giving magnesium sulphate 4g IV loading dose followed by 1gm/hr infusion for 24hrs saves lives and prevents further seizures in women with eclampsia.

KEENER KONTEST:

Last weeks winner of the Keener Kontest was Dr. A. Radan of Homesville, Ontario. He knew that you should be skeptical of anything you learn/taught, even if you learned/taught it on TheSGEM.

This weeks Keener Kontest question is what book did the quote “Don’t Panic” come from?

Email your answer to TheSGEM@gmail.com or go to the “Contact Us” link at the top of the home page. Use “Keener Kontest” in the subject line. First one to email me the correct answer will win a cool skeptical prize:)

    SkiBEEM 2013
    Silver Star, BC
    February 4-6.

Here are some book titles from TheSGEM Book Club. These are recommended for people interested in critical and skeptical thinking. For a full list of books check out the ADDITIONAL RESOURCES tab at the top menu.

• Mistakes Were Made (but not by me) – Carol Tavis and Elliot Aronson
• Ignorance: How it drives science – Stuart Firestein
• The Great Cholesterol Con - Malcom Kendrick
• The Emperor’s New Drugs: Exploding the antidepressant myth - Irving Kirsch
• Overtreated: Why too much medicine is making us sicker and poorer - Shannon Brownlee
• Over-Diagnosed: Makling people sick in the pursuit of health - Go;bert Welch
• The Creative Destruction of Medicine - Eric Topol
• 50 Popular Beliefs that People Think are True - Guy P. Harrison

Have you read a book you really thought was great? If you want to share it with TheSGEM audience please send me and email at TheSGEM@gmail.com. I will take a look and see about posting it on the site.

I had the pleasure of being interviewed by Dr. Greg Henry former ACEP president. EP Monthly set the stage and the rest just happened.

There are six short clips which discuss knowledge translation/dissemination using social media. Access them by going to TheSGEM’s YouTube feed or clicking on EP Monthly.

Don’t forget of course to like us on FaceBook, follow us on Twitter and subscribe to the iTunes feed.

Follow us on Facebook, Twitter, iTunes, and/or YouTube  to keep up to date with the latest podcasts and EBM-related news!

]]> http://thesgem.com/2012/10/follow-the-sgem/feed/ 0 http://thesgem.com/2012/10/pubcast6-orthopedic-surgeons-strong-and-smart/ http://thesgem.com/2012/10/pubcast6-orthopedic-surgeons-strong-and-smart/#comments Sun, 07 Oct 2012 13:03:53 +0000 admin http://thesgem.com/?p=201 log in/register to view this content.]]> http://thesgem.com/2012/10/pubcast6-orthopedic-surgeons-strong-and-smart/feed/ 2 0:10:02 Please log in/register to view this content. Please log in/register to view this content. Featured, Musculoskeletal, Podcasts Dr. Ken Milne no no http://thesgem.com/2012/10/why-we-need-ebm-in-the-ed/ http://thesgem.com/2012/10/why-we-need-ebm-in-the-ed/#comments Thu, 04 Oct 2012 14:07:54 +0000 admin http://thesgem.com/?p=309 log in/register to view this content.]]> http://thesgem.com/2012/10/why-we-need-ebm-in-the-ed/feed/ 1 http://thesgem.com/2012/10/thats-the-way-i-like-it/ http://thesgem.com/2012/10/thats-the-way-i-like-it/#comments Tue, 02 Oct 2012 18:49:22 +0000 admin http://thesgem.com/?p=300 log in/register to view this content.]]> http://thesgem.com/2012/10/thats-the-way-i-like-it/feed/ 1 http://thesgem.com/2012/09/podcast5-does-johnny-kneed-an-x-ray/ http://thesgem.com/2012/09/podcast5-does-johnny-kneed-an-x-ray/#comments Sun, 30 Sep 2012 16:49:24 +0000 admin http://thesgem.com/?p=196 log in/register to view this content.]]> http://thesgem.com/2012/09/podcast5-does-johnny-kneed-an-x-ray/feed/ 2 0:05:34 Please log in/register to view this content. Please log in/register to view this content. Featured, Musculoskeletal, Podcasts Dr. Ken Milne no no http://thesgem.com/2012/09/podcast4-getting-un-stoned/ http://thesgem.com/2012/09/podcast4-getting-un-stoned/#comments Sun, 16 Sep 2012 20:48:42 +0000 admin http://thesgem.com/?p=187 log in/register to view this content.]]> http://thesgem.com/2012/09/podcast4-getting-un-stoned/feed/ 4 0:07:42 Please log in/register to view this content. Please log in/register to view this content. Featured, Genitourinary, Podcasts Dr. Ken Milne no no http://thesgem.com/2012/09/podcast3-to-xray-or-not-to-xray/ http://thesgem.com/2012/09/podcast3-to-xray-or-not-to-xray/#comments Sun, 16 Sep 2012 19:59:18 +0000 admin http://thesgem.com/?p=170 log in/register to view this content.]]> http://thesgem.com/2012/09/podcast3-to-xray-or-not-to-xray/feed/ 0 0:11:07 Please log in/register to view this content. Please log in/register to view this content. Featured, Musculoskeletal, Podcasts Dr. Ken Milne no no http://thesgem.com/2012/09/podcast2-evidence-based-medicine/ http://thesgem.com/2012/09/podcast2-evidence-based-medicine/#comments Sun, 16 Sep 2012 19:53:06 +0000 admin http://thesgem.com/?p=163 log in/register to view this content.]]> http://thesgem.com/2012/09/podcast2-evidence-based-medicine/feed/ 0 0:09:50 Please log in/register to view this content. Please log in/register to view this content. Featured, Podcasts Dr. Ken Milne no no http://thesgem.com/2012/09/podcast-1-introduction-to-thesgem/ http://thesgem.com/2012/09/podcast-1-introduction-to-thesgem/#comments Sun, 16 Sep 2012 19:37:58 +0000 Scott Odorizzi http://thesgem.com/?p=156 log in/register to view this content.]]> http://thesgem.com/2012/09/podcast-1-introduction-to-thesgem/feed/ 0 0:06:16 Please log in/register to view this content. Please log in/register to view this content. Featured, Podcasts Dr. Ken Milne no no http://thesgem.com/2012/07/skibeem-2013-conference/ http://thesgem.com/2012/07/skibeem-2013-conference/#comments Thu, 05 Jul 2012 23:03:55 +0000 Scott Odorizzi http://thesgem.com/?p=88 Best Evidence in Emergency Medicine