R&R In The FASTLANE 137

Welcome to the 137th edition of Research and Reviews in the Fastlane. R&R in the Fastlane is a free resource that harnesses the power of social media to allow some of the best and brightest emergency medicine and critical care clinicians from all over the world tell us what they think is worth reading from the published literature.

This edition contains 6 recommended reads. The R&R Editorial Team includes Jeremy Fried, Nudrat Rashid, Soren Rudolph, Anand Swaminathan and, of course, Chris Nickson. Find more R&R in the Fastlane reviews in the : Overview; Archives and Contributors

This Edition’s R&R Hall of Famer

Goyal M et al. Endovascular thrombectomy after large-vessel ischaemic stroke: a meta-analysis of individual patient data from five randomised trials. Lancet 2016. PMID 26898852

• This is a meta-analysis of patient level data taken from the 5 recent endovascular stroke treatment trials (MR CLEAN, ESCAPE, REVASCAT, SWIFT PRIME, EXTEND IA) and the authors taut an NNT of 2.6 for improvement. However, the data here is presented in a loaded fashion. This incredible NNT is for the endpoint of an ordinal shift or improvement of 1 point on the modified Rankin Scale. This measure has long been thought useless for stroke since going from a 6 (dead) to a 5 (severe disability) or from a 1 (no significant disability) to a 0 (no symptoms) is irrelevant and aren’t equal outcomes. The more relevant endpoint (mRS 0-2 at 90 days) still yields an impressive NNT = 5. Unfortunately, the authors bury incredibly relevant information like the strict imaging criteria used in these studies and the fact that only a tiny number of stroke patients meet criteria based on these studies. Finally, the COI list is long and convoluted as always. Is this intervention useful in a small minority of patients? Probably. Should we all be changing our stroke care systems to meet this need? Probably not.

• Recommended by Anand Swaminathan
• Read more at Endovascular for Stroke: Even better than the evidence (EM Literature of Note)

Sieweke N et al. Cardiac Troponin I elevation after epileptic seizure. BMC Neurol 2012. PMID 22804867

• Apparently seizures can elevate troponin-I (but not trop-T). Who knew? Possibly secondary to vascular disease so maybe it’s a type-2 MI of some sort? Very strange.
• Recommended by Seth Trueger

Wasserstein RL et al. The ASA’s statement on p-values: context, process, and purpose. The American Statistician. 2016. DOI 10.1080/00031305.2016.1154108

• Statistical significance and p values are widely touted, proudly displayed, and increasingly reported. Yet p values are problematic, so much so the American Statistical Association created a statement essentially calling the literature out for misuse. P values indicate how incompatible the data are with a specific statistical model. They NEITHER reflect the probability that the null hypothesis is true (they are calculated assuming the null hypothesis is true) NOR the probability that the data were produced by chance alone. P values also do not measure effect size or significance. We see a great deal of research overturned and it appears that misused statistics may be to blame. Handle p values cautiously.
• Recommended by Lauren Westafer

Long B et al. Resuscitating the tracheostomy patient in the ED. Am J Emerg Med. 2016 Mar 23. PMID 27073134

• Patients with tracheostomies often invoke some fear and commotion in the ED. This well written to-the-point paper on management of the patient with tracheostomy provides the basic need-to-know stuff and an algorithm for handling the most common emergencies.
• Recommended by Søren Rudolph

Morris JR et al Comparative Trends and Downstream Outcomes of Coronary CT Angiography and Cardiac Stress Testing in Emergency Department Patients with Chest Pain: An Administrative Claims Analysis. Acad Emerg Med. 2016 PMID 27155236

• This is an analysis of a large administrative claim data (OPTUM labs, a type of “big data” warehouse). The authors look at the rate of CT Coronariogram use in the last several years and subsequent healthcare utilization. Interestingly, the use has increased 4-5 fold, and problematically, the downstream use of resources in those patients has increased. In practicality, the use of CTca is associated with increase of further stress testing, invasive procedures and re-admissions. Looks like CTca is not beneficial in people with moderate to high risk chest pain, and is only helpful in people with low risk who arguable don’t need any sort of advanced testing.
• Recommended by Daniel Cabrera

Freedman SB et al. Effect of Dilute Apple Juice and Preferred Fluids vs Electrolyte Maintenance Solution on Treatment Failure Among Children With Mild Gastroenteritis: A Randomized Clinical Trial. JAMA 2016. PMID 27131100

• Kids just want to drink juice, but I’ve been told forever that if I let kids with gastro drink juice they would die (or something like that). This is a randomized, controlled non-inferiority trial out of the Hospital for Sick Children that compared electrolyte solution to a combination of half strength apple juice in the ED and the child’s preferred fluid (juice or milk) at home. Put simple, the apple juice group had fewer treatment failures. There were a few weakness in the study, including the fact that is was a single centre study, included only children with mild (or no) dehydration, and used a composite outcome that might not have been entirely clinically relevant to me. However, this is a game changer for me. I am switching to juice for kids with gastro, and I know they will be happier for it.
• Recommended by Justin Morgenstern