First10EM Journal Club: November 2019

We are back!  Another journal club with Dr Justin Morgenstern.  This month we have a really diverse bunch of papers that looks at CRASH-3, distraction techniques for kids in ED, making the patient experience better, wound closure and syncope workup (Spoiler: CTs ain’t that great).

As always the full-text PDFs are available at the cost of a click below.

We mention the Broome Rural Anaesthesia Conference for RADU which is soon to open for registration.  You can check out the flyer at the website if you are an Aussie or Kiwi GP-Anaesthetist looking for a warm winter vacation and edification.

OK, onto the papers!

CRASH 3 – A world where no change in mortality transforms into 10s of thousands of lives saved

The CRASH-3 Trial Collaborators. Effects of tranexamic acid on death, disability, vascular occlusive events and other morbidities in patients with acute traumatic brain injury (CRASH-3): a randomised, placebo-controlled trial. Lancet (London, England). 2019; PMID: 31623894 [free full text]

You can read more about CRASH3 and why disease specific mortality is a bad outcome here.

Watanabe BL, Patterson GS, Kempema JM, Magallanes O, Brown LH. Is Use of Warning Lights and Sirens Associated With Increased Risk of Ambulance Crashes? A Contemporary Analysis Using National EMS Information System (NEMSIS) Data. Annals of emergency medicine. 2019; 74(1):101-109. PMID: 30648537

Esmailian M, Azizkhani R, Jangjoo A, Nasr M, Nemati S. Comparison of Wound Tape and Suture Wounds on Traumatic Wounds’ Scar. Advanced biomedical research. 2018; 7:49. PMID: 29657934 [free full text]

Sklar LR, Pourang A, Armstrong AW, Dhaliwal SK, Sivamani RK, Eisen DB. Comparison of Running Cutaneous Suture Spacing During Linear Wound Closures and the Effect on Wound Cosmesis of the Face and Neck: A Randomized Clinical Trial. JAMA dermatology. 2019; 155(3):321-326. PMID: 30649154

Graham B, Endacott R, Smith JE, Latour JM. ‘They do not care how much you know until they know how much you care’: a qualitative meta-synthesis of patient experience in the emergency department. Emergency medicine journal : EMJ. 2019; 36(6):355-363. PMID: 31003992

İdil H, Kılıc TY. Diagnostic yield of neuroimaging in syncope patients without high-risk symptoms indicating neurological syncope. The American journal of emergency medicine. 2019; 37(2):228-230. PMID: 29802003

White JL, Hollander JE, Chang AM, et al. Orthostatic vital signs do not predict 30 day serious outcomes in older emergency department patients with syncope: A multicenter observational study. The American journal of emergency medicine. 2019; PMID: 30928476

You can read more here.

Vukovic AA, Poole MD, Hoehn EF, Caldwell AK, Schondelmeyer AC. Things Are Not Always What They Seem: Two Cases of Child Maltreatment Presenting With Common Pediatric Chief Complaints. Pediatric emergency care. 2019; 35(6):e107-e109. PMID: 30489490

Fogarty E, Dunning E, Koe S, Bolger T, Martin C. The ‘Jedward’ versus the ‘Mohawk’: a prospective study on a paediatric distraction technique. Emergency medicine journal : EMJ. 2014; 31(4):327-8. PMID: 23629154

Inan G, Inal S. The Impact of 3 Different Distraction Techniques on the Pain and Anxiety Levels of Children During Venipuncture: A Clinical Trial. The Clinical journal of pain. 2019; 35(2):140-147. PMID: 30362982

Brahmania M, Renner EL, Coffin CS, et al. Choosing Wisely Canada-Top Five List in Hepatology: Official Position Statement of the Canadian Association for the Study of the Liver (CASL) and Choosing Wisely Canada (CWC). Annals of hepatology. ; 18(1):165-171. PMID: 31113586 [free full text]


  1. Comments from the very smart Dr Michael Tam (Sydney):

    Casey Parker – great stuff. After reading the link to the critical appraisal on TXA for trauma, I was reminded of the problems with significance testing in subgroup analysis.
    The problem is that it is difficult, I suspect, for most people/readers to reframe that these results are not confirmatory type tests but exploratory. I’ve recently started thinking that most of these dichtomised subgroups may be spurious. Simply, if we are doing data exploration, why dichtomise at all and do an inferential test? We could create a visualisation of the entire range of data rather than lumping it into two groups.
    For instance, if we are looking at the effect of GCS on the outcome (even a binary outcome like mortality), you could simply create a jitterplot with GCS as the x-axis, and survival (0 is died, 1 is survived) on be y. That is, all data points will be at 0 or 1, but the DENSITY of the data will change across the GCS range. You could then plot a local regression curve across the GCS range and this will provide a crude estimate of the proportion of people who survived. Overlaying the plots for people on TXA vs people in placebo will give a much better sense of the uncertainty in the estimates and whether there is an apparent real phenomenon that TXA and placebo has different effects.

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