My correspondence regarding this article was published in Stroke a couple days ago. I’d like to say the author response is earth-shattering and insightful, but while it is not, they were kind enough to respectfully reply.
Sadly, the correspondence and response is available only to subscribers – but I have PDFs available for educational purposes….
“Letter by Radecki Regarding Article, ‘Safety of Thrombolysis in Stroke Mimics: Results From a Multicenter Cohort Study'”http://stroke.ahajournals.org/content/early/2013/08/08/STROKEAHA.113.002040.full.pdf+html
Month: August 2013
Observation of Minor TBI Prevents Harms
This study regarding the observation of children following minor traumatic brain injury is a little bit oddly spun by its authors and the medical news.
As we all know, most children presenting to the Emergency Department for minor head trauma do not have a clinically significant injury. Regardless, a significant portion of these children receive non-therapeutic cranial radiation to further assure parents and clinicians alike. The PECARN group, a few years back, published a rough decision instrument to help classify ~50% of these patients as “very low risk” (<0.05% risk of TBI) to give clinicians a tool to obviate CT scanning.
This group at Boston Children’s prospectively evaluated clinicians’ use of immediate CT scanning versus delayed CT scanning (observation). They find, of course, that observing children in the ED for a short period, rather than making an immediate decision regarding CT use, resulted in decreased use of CT. Thusly, the press releases state “Waiting and Watching Can Reduce Use of Brain Scans for Kids in the Emergency Department“.
But, watching and waiting doesn’t benefit the children in this cohort – other than preventing avoidable harms. The eight children who had CT scans showing clinically important injuries were easily identified by clinicians as requiring immediate CT. The period of observation doesn’t change the short-term clinical outcome of any of the patients – it only “treats” the risk-aversion of clinicians and parents. “Watching and waiting” may reduce scans – but discharging the entire observation cohort immediately would have reduced scans even further, without missed cTBI (although the study is underpowered to truly detect all events down to an appropriate “zero-miss” threshold).
While I agree this is an important clinical problem to address, I simply find an odd discordance between the patient-oriented features and the resource utilization-oriented outcome measured.
“Effect of the Duration of Emergency Department Observation on Computed Tomography Use in Children With Minor Blunt Head Trauma”
www.ncbi.nlm.nih.gov/pubmed/23910481
More Sales Representatives, More Stents
In this breaking news update: sales representatives sell things! Thusly, their company stays in business, and the employment of the sales representative continues.
This is a retrospective review of a Canadian hospital’s cardiac catheterization practices, evaluating the association between presence of sales representatives for stent manufacturers and use of each company’s stents during PCI. Each day, during normal business hours, potentially a single sales representative from one of five stent manufacturers could be present in the lounge or in one of three cardiac catheterization laboratories. Certain manufacturers specialized in bare metal stents, drug-eluting stents, or antibody-coated stents.
Unsurprisingly enough, cases performed in the presence of a sales representative resulted in increased use of that particular representative’s stents. Additionally, for cases where DES were deployed, on average, more stents were placed during PCI when a drug representative was present. Increased stenting, increased per-patient average cost.
It is a retrospective review, and there are baseline differences between the indications for catheterization – but, I think the observed association is probably real. The authors also note, after these promotional visits were discontinued, all variation in stent use disappeared.
Further evidence of the suggestibility of physicians to marketing influences – supporting efforts to expunge them from our practice settings.
“The impact of industry representative’s visits on utilization of coronary stents”
www.ncbi.nlm.nih.gov/pubmed/23895808
Red Pill, Blue Pill, Video Pill
As these authors note, upper GI hemorrhage is responsible for almost 600,000 Emergency Department visits yearly – and there is some value and interest in risk-stratifying the suspect lesion with direct visualization. Enter the gastroenterologist.
But, wait! What if you could replace the on-call gastroenterologist and his endoscope with – a pill? That was the question these researchers, funded by an unrestricted grant from the capsule endoscopy manufacturers, tried to address.
Sadly, their study design is woefully inadequate – except for producing positive findings to return the favor to their funding source. A convenience sampling of 126 Emergency Physicians attending a conference watched four videos clipped only to footage of the stomach, three of which had blood present, and one of which did not. These physicians missed a few (94% sensitivity) and overcalled a few more (87% specific) from these handpicked test videos.
So, we have a surrogate endpoint for patient-oriented outcomes, an idealized simulated setting that is non-equivalent to clinical practice, and conflicts of interest with the manufacturer. The authors mention high “cost of capsule endoscopy” – and, at this point, I cannot see how this study does anything other than mislead readers this might be appropriate for an Emergency Department setting.
“Emergency Physicians Accurately Interpret Video Capsule Endoscopy Findings in Suspected Upper Gastrointestinal Hemorrhage: A Video Survey”
www.ncbi.nlm.nih.gov/pubmed/23859585
Where Is My: Coffee. Where is it.
Most modern vices seem to be, at the minimum, associated with some substantial harms. Excessive sun exposure, rich western diets, scotch, sloth, etc. And, then there’s coffee.
This is a review article covering the evidence behind various cardiovascular associations uncovered regarding the consumption of coffee. After noting coffee contains thousands of compounds, the most prominent of which are caffeine, alcohols, antioxidants, and anti-inflammatories, the authors review the effects on various cardio-metabolic risk factors.
In brief, coffee consumption conferred:
- No observed effect on blood pressure.
- Decreased association with Type II diabetes.
- Uncertain relationship with serum lipds.
- A U-shaped relationship with congestive heart failure.
- Decreased incidence of coronary heart disease.
- Fewer cardiac arrhythmias.
- Reduced risk of stroke.
- Decreased risk of death.
Obviously, many of these findings are observational and potentially confounded by many other factors. But, at the least – despair not of your coffee addiction.
“Effects of Habitual Coffee Consumption on Cardiometabolic Disease, Cardiovascular Health, and All-cause Mortality”
www.ncbi.nlm.nih.gov/pubmed/23871889