Sep 30, 2016

Quick study

The story

You're a different person when you're buttoned in your interview suit, and drugs are different when they're trapped in clinical trial protocols. Researchers are thinking of new ways to give investigative meds some breathing room. 

The basics

Think from the perspective of a drug company funding new studies: they need to see if a new treatment is safe and beneficial in ideal settings. Your typical phase III RCT is tied to tightly wound inclusion and exclusion criteria. Participants are closely watched and often treated at large academic centers.  

Get practical

With phase III RCTs, it may be hard to see how trial results apply to the patients you care for on the day-to-day. Elderly, frail, and complex patients are likely excluded to help researchers focus on simple cause and effect for the drug in question. Pragmatic trials show evidence for a treatment in a real world setting, and can help better estimate the public health effect of broad interventions.

An example, please

Look no further than the Salford Lung Study, a trial of fluticasone furoate–vilanterol (Breo Ellipta), a once-daily inhaler for COPD. The 2,800 patient trial looked at the medication's use in a British community served by a single hospital and EMR, with minimal exclusion criteria and no additional patient monitoring outside of normally scheduled outpatient visits. The med reduced exacerbation rates compared to usual care in high-risk COPD patients. While typical COPD trial participants represent about 10% of actual patients with the disease, the investigators think their results apply directly to general practice. 

Say it on rounds

When your Seamless arrives earlier than expected

Go ahead and smile. Say the same and more to patients fortunate enough to undergo early endovascular thrombectomy – roughly defined as when your ever-pleasant buddies from IR snag a blood clot with a retrieval device – after acute ischemic stroke. A 1,200 patient meta-analysis found individuals revascularized within 7 hours of symptom onset had significantly better disability scores compared to those treated with medical therapy alone. Each 1-hour delay in reperfusion correlated with worse disability scores and less functional independence at 3 month follow-up. 

When the end of rounds is nowhere in sight

Maybe it's time to suggest a 90-minute limit to your attending. The sub-90 goal also applies to door-to-device time in STEMI patients, where overall transfer time from the field to the cath lab is critical. A small South Korean trial observed an average improvement in total transfer time of 27 minutes with a smartphone app-based networking system. ED docs used the social messaging app BAND to deliver an EKG and basic patient information to PCI-capable facilities, who then prepared in advance for patient arrival. The study was underpowered to detect differences in clinical outcome.

When you finish your scut list before noon conference

Think fast and work quickly if you want to get home on time. The speed approach also works in cardiac arrests, where investigators evaluated chest compression speed in an observational study of over 200 patients. Compressions performed at a rate of 120 - 140 per minute were more likely to achieve return of spontaneous circulation (ROSC) than those performed at 100 - 120 per minute as suggested by current ACLS guidelines. Rates above 140 per minute were less effective. 

Brush up

Acute sinusitis

Winter is coming, and not just for Jon Snow. Your walk-in-clinic is bracing for hoards of patients with colds of indeterminate length, and they all want antibiotics. Look for purulent nasal discharge accompanied by nasal obstruction, facial pain, pressure, or fullness that persists for at least 10 days without improvement or worsens within 10 days after initial improvement to diagnose acute sinusitis. Want symptom control? Try analgesics, nasal irrigation with saline, or decongestants. But that’s not the money question…

What's the evidence

For antibiotics vs. watchful waiting in acute sinusitis? A 2012 RCT of 160 patients with sinusitis found no difference between amoxicillin and placebo at day 3 of treatment. Citing a minor clinical benefit and a high prevalence of adverse events, a Cochrane review from the same year recommended against antibiotics in uncomplicated acute sinusitis. 

What your physics friends are talking about

Forget cystoscopy or expensive extractions: kidney stones may be best passed from the back of a roller coaster. The secret is in centripetal force

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