R&R In The FASTLANE 162

Welcome to the 162nd 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 5 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

Ioannidis JP. Evidence-based medicine has been hijacked: a report to David Sackett. Journal of clinical epidemiology. 73:82-6. 2016. PMID: 26934549

• This is just one of those papers that everyone should take the time to read. Written in the form of a letter to and eulogy for the great Dr. David Sackett, this beautifully written paper describes how industry has hijacked evidence based medicine by performing very high quality studies that ask the wrong questions or measure the wrong outcomes.
• Recommended by Justin Morgenstern

Daniels L et al. Randomized clinical trial of observational versus antibiotic treatment for a first episode of CT-proven uncomplicated acute diverticulitis. The British journal of surgery. 2016. PMID: 27686365

• Another randomized trial supports a no-antibiotic strategy for diverticulitis. Now, the question is to figure which patients probably do actually benefit.
• Recommended by Ryan Radecki
• Read more: Antibiotics for diverticulitis, the end must be near (Emergency Medicine Literature of Note)

Yarema MC et al. “Can a serum acetaminophen concentration obtained less than 4 hours post-ingestion determine which patients do not require treatment with acetylcystine?” Clin Tox 2016. PMID: 27788602

• Increasing pressures on ED physicians to obtain early dispositions, combined with pharmacokinetic data showing therapeutic acetaminophen levels peak under one hour has led many to consider utilization of an early (<4-hour post-ingestion) acetaminophen level to exclude toxicity after overdose. This large retrospective study addresses the issue of using acetaminophen levels <100 mcg/mL drawn 2 to 4 hours post-ingestion to rule out toxicity. Although the authors found these early levels to be generally very good in predicting toxicity, they were not sufficiently sensitive to be used in practice. Authors note that these early levels may be applicable and safe in certain subgroups such as pediatric liquid acetaminophen ingestions, however larger prospective studies are needed to identify these groups. The 4-hour Rumack-Matthew nomogram for acute acetaminophen overdose remains best practice.
• Recommended by Meghan Spyres

Klang E et al. Overuse of Head CT Examinations for the Investigation of Minor Head Trauma: Analysis of Contributing Factors. Journal of the American College of Radiology. 2016. PMID: 27836434

• We have historically imaged too many people with minor head trauma. Most of us are trying to stop. This retrospective chart review found 37% of head CTs after minor head trauma in patients <65 years old at one medical center were not indicated per the Canadian CT Head decision aid (CCHR). They found attending status (vs resident) and neurology specialty were associated with ordering CT scans not indicated by the CCHR. Unfortunately this study suffers from a lack of methods on how they performed their chart review. However, providers undoubtedly perform excessive head CTs and evaluation of local trends may help guide local educational endeavors (or computerized ordering criteria) to curb these CTs
• Recommended by Lauren Westafer

Donaldson L et al. Review article: Why is there still a debate regarding the safety and efficacy of intravenous thrombolysis in the management of presumed acute ischaemic stroke? A systematic review and meta-analysis. Emergency medicine Australasia : EMA. 2016. PMID: 27561375

• Put simply, this systematic review proves that stroke thrombolysis is an unproven therapy.
• Recommended by Chris Nickson