Journal Club Podcast for October 2021
Prof Peter Cameron
Dr Divya Karna
Dr Eanna Mac Suibhne
Editor: Dr David McCreary
Welcome to the Journal Club Podcast for October 2021. You can listen to the podcast above and have a read at our summary below, courtesy of our senior registrar for research, Dr Eanna Mac Suibhne.
Paper 1: Direct to Angiography Suite Without Stopping for Computed Tomography Imaging for Patients With Acute Stroke
Should we bypass the CT scanner and head directly to the angio suite in patients suspected of large vessel occlusion within 6 hours of symptom onset? The researchers looked for any difference in functional outcomes between two groups of patients as measured by the Modified Rankin Scale at 90 days.
In this randomized clinical trial, 147 patients were randomised. 74 entered the interventional group and went directly to the angiography suite and 73 into the control group and underwent conventional workflow. The primary outcome analysis showed an adjusted common odds ratio of improvement of 1 point on the Modified Rankin Scale of 2.2 favouring direct to angiography.
For patients with LVO admitted within 6 hours after symptom onset, this randomized clinical trial found that, compared with conventional workflow, taking patients directly to the Angio suite increased the odds of patients undergoing EVT, decreased hospital workflow time, and improved clinical outcome.
Journal Club Thoughts
We are always looking for ways to reduce the time to get our Stroke patients the appropriate imaging and correct treatment, so this paper looks at a very important topic and this paper certainly challenges us and what we can aspire to.
Unfortunately, not all hospitals have the infrastructure or equipment to introduce a similar pathway as the team in Barcelona have so ably managed to do [insert business case proposal for a Flat panelled CT here].
The study was well constructed but a few issues were raised, one of which we looked at was how virtually 100%, got clot retrieval in the interventional arm and whether this possibly opened the study to bias.
Secondly, early termination of the trial made it unpowered to detect differences between groups regarding safety variables, and an interim analysis may have overestimated the real treatment effect.
Finally, in this paper, we are also dealing with small numbers from a single centre and basing a whole stroke pathway on this might be problematic. Larger studies with more patients would be needed before recommending it for every stroke centre.
Paper 2: Effect of Intravenous Fluid Treatment With a Balanced Solution vs 0.9% Saline Solution on Mortality in Critically Ill Patients
10.1001/jama.2021.11684 (balanced vs saline paper)
10.1001/jama.2021.11444 (slower vs bolus rate fluids)
This trial posed two questions, which were reported in two separate papers. In critically ill adult ICU patients requiring IV fluids, does a balanced solution provide benefits over 0.9% Na Cl in terms of 90-day all-cause mortality? Secondly, does a slow infusion rate compared to a fast infusion rate of a fluid bolus provide improvement in the same terms?
Double-blind, factorial, randomized clinical trial conducted at 75 ICUs in Brazil.The population studied included any patient admitted to the ICU with a need for fluid resuscitation, were note expected to be discharged the day after admission and had at least one risk factor for AKI.
Among 10 520 patients in intensive care units, intravenous fluid bolus treatment with a balanced solution vs saline solution resulted in 90-day mortality of 26.4% vs 27.2%, respectively, a difference that was not statistically significant. In the second outcome, rapid vs slow administration, there was no significant difference in 90 -day mortality, again a difference which was not statistically significant
Among critically ill patients requiring fluid challenges, use of a balanced solution compared with 0.9% saline solution did not significantly reduce 90-day mortality. The findings do not support the use of this balanced solution
Journal Club Thoughts
A large trial and a controversy that just doesn’t go away. There were some issues, albeit a study with great internal validity.
For an EM audience, a large portion of the patients involved in this study were not of the calibre that we would be sending to the ICU from Resus, around 40% were planned surgical admissions. Fluids which were given pre- ICU were not accounted for and the amount of fluid given while in ICU was relatively low so you would wonder if the type and volume of fluid could have made more of an impact on sicker patients.
But it’s reassuring that small amounts of 0.9% NaCl may not be harmful, the initial phase of resuscitation
Also, a hypothesis generating question arose with patients fluid administration in patients with traumatic brain injury in the subgroup analysis. Watch this space.
Paper 3: Diagnostic Accuracy of Lung Point-Of-Care Ultrasonography For Acute Heart Failure Compared with Chest X-Ray Study Among Dyspneic Older Patients in the Emergency Department
Among patients presenting to the ED with undifferentiated dyspnoea, does POCUS provide additional diagnostic capacity over clinical assessment and chest X-ray?
This was a cohort study with additional health records review. The reference standard was discharged diagnosis, ED diagnosis and confirmation by another physician or diagnosis made by health record reviews. The results revealed a sensitivity and specificity of 92.5% and 85.7% respectively in the POCUS group which was superior to the 63.3% sensitivity and 92.9% specificity of radiology reading of Chest X-ray.
Lung POCUS performed by emergency physicians in a real clinical setting was highly sensitive and specific in identifying acute heart failure and had higher sensitivity than chest x-ray among older patients with suspected AHF or COPD in their ED stay
Journal Club Thoughts
The main issue with study is what the gold standard is. If the standard being used is having the emergency physicians both do the test and say what the diagnosis is it weakens the internal validity of the study.
Ideally, if the diagnosis was made independently by a separate physician and the US was being conducted by a separate, independent user, this would strengthen the methodology.
In the undifferentiated dyspnoeic patient, making the most accurate diagnosis is important in order to implement appropriate treatment in a timely manner, and there are many other studies out there which detail the advantages of POCUS in this patient cohort.
Paper 4: One Versus 3-Week Immobilisation Period for Nonoperatively Treated Proximal Humeral Fractures. A Prospective Randomized Trial.
Among patients with proximal humeral fractures discharged from the ED, how long should the arm be immobilised?
The researchers conducted a prospective randomised trial to determine whether a one week or a three-week immobilisation period would be more effective if it came to pain and functional outcome.
Overall, 111 patients were enrolled in the final analysis. There was no significant differences found between the 2 groups when it came to pain, neither was there any significant difference in the constant score or the simple shoulder test scores between the 2 groups. Complication rates were also similar.
Short and long immobilisation periods yielded similar results for non-operatively treated proximal humeral fractures, independent of fracture pattern. These fractures can be successfully managed with a short immobilization period of1 week in order to not compromise patients’ independence for an extended period.
Journal Club Thoughts
An interesting study, quite big numbers for this type of trial. One of the main limitations is the lack of consensus between centres in how these types of fractures are managed as the group of patients which the Orthopaedic surgeons chose not to operate on may affect generalisability.
This was an important patient centred study as the majority of these patients are elderly ( as displayed by the studies baseline characteristics) who really could do with use of their upper limbs to conduct their ADL’s.
There was lack of difference between the groups in terms of complication rates was somewhat reassuring however, 20 % of patients were lost to follow up here which does affect the interpretation of the results. It was noted in the Journal Club there is that signal of increased secondary displacement in the early mobilisation group – the study wasn’t powered to assess the significance of this, but it’s worthy of consideration.
Making sure your patients get appropriate and timely follow up will probably affect you decision in terms of duration of immobilisation, so have a look at what your hospital offers!
- Requena M, Olivé-Gadea M, Muchada M, Hernández D, Rubiera M, Boned S, et al. Direct to Angiography Suite Without Stopping for Computed Tomography Imaging for Patients With Acute Stroke. Jama Neurol. 2021;78(9):1099–107.
- Zampieri FG, Machado FR, Biondi RS, Freitas FGR, Veiga VC, Figueiredo RC, et al. Effect of Intravenous Fluid Treatment With a Balanced Solution vs 0.9% Saline Solution on Mortality in Critically Ill Patients. Jama. 2021;326(9):818–29.
- Nakao S, Vaillancourt C, Taljaard M, Nemnom M-J, Woo MY, Stiell IG. Diagnostic Accuracy of Lung Point-Of-Care Ultrasonography for Acute Heart Failure Compared With Chest X-Ray Study Among Dyspneic Older Patients in the Emergency Department. J Emerg Medicine. 2021;61(2):161–8.
- Martínez R, Santana F, Pardo A, Torrens C. One Versus 3-Week Immobilization Period for Nonoperatively Treated Proximal Humeral Fractures: A Prospective Randomized Trial. J Bone Joint Surg. 2021;103(16):1491–8.