Dr. Aditya Makol

Weekly Research Article

Week 3 of the weekly research article!

Looking this week at a recent major article from the NEJM called “EXTEND TPA.” Will likely be used to advocate for perfusion/mismatch imaging as a means of extending the TPA window based on the authors’ conclusions that there was a statistically significant difference after adjusting for confounders.

However, the methodology of this article is highly questionable. It was stopped early after the WAKE UP trial was published last summer, because the authors felt there was a “lack of equipoise.” They recruited only 60% of their calculated sample size, and the true p value between the two arms was 0.35.

The additional step of adjusting for confounders is a method used largely for observational or retrospective studies. It does not apply for a RCT that is designed to screen for and appropriately randomize patients. The original IRB approval was for an unadjusted study, and the first mention of adjusting the numbers was after final data collection.
The patient populations in Table 1 are also not that different. Either way, the reported p value of 0.04 is flawed statistics. A better means of obtaining accurate results would have been to not stop the trial early and follow the original protocol.
Week 2 of the weekly research article!
This week’s topic focuses on on opioid overdose and how to best help these high-risk patients after they leave the ED.
1. Weiner 2019 – large sample size retrospective review (11000 patients) of patients who were discharged from the ED following an overdose and mortality outcomes within next year. Found an approximately 5% mortality within 12 months, 1% within 1 month, and found a rate of about 2/3 coming from subsequent overdoses.
2. Kestler 2017 – smaller Canadian study that looked at the large gap between utilization of narcan kits and patient willingness to take narcan home. 2/3 of patients were interested in having access and accepted, but only 15% had ever received narcan kits prior to study and providers reported a 2% rate of having offered kits to patients in past. Caveat that may be tough to directly compare across international healthcare systems.
3. Gottlieb 2017 – small meta-analysis showing that providing a2-agonists, especially clonidine, decreases symptoms of severe withdrawal and promotes longer duration of rehab/detox compared to placebo.
4. Love 2018 – moderate size meta-analysis showing that buprenorphine is even better for same outcomes compared to clonidine. Both #3 and 4 are primarily outpt based, so role of how to best start this process in the ED is still evolving.
Week 1 of the weekly research article!
Narrowed it down to 4 and couldn’t decide. They’re all things I think we 100% need to know as residents and attendings and I teach the first 2 to every junior regularly.
So, I’ll let you guys decide, or (my vote) post at least 2+.
1. Corl 2017 – IVC collapsibility DOES help in non-intubated patients. I’ve heard misconceptions that there’s no data for this, and printed out this article to give to juniors who had heard otherwise.
2. Pivetta 2019 – POCUS is better than CXR/BNP to assess for ADHF.
3. Cortellaro 2017 – cool study that shows that POCUS can identify septic source within 10 mins in 73% of undifferentiated sepsis, compared to routine care at 53% within 3 hrs
4. Atkinson 2019 -Cardiac activity on POCUS helps prolong duration of CPR and lead to better outcomes compared to lack of cardiac activity on POCUS (self-explanatory) but more importantly compared to cases with no POCUS at all. Suggests we can occasionally abandon our codes too early.