First10EM Journal Club: June 2026

Welcome to the June 2026 edition of the podcast. We are tackling all of our favourite subjects – PE, trauma, stroke, COVID, contrast controversies and prehistoric dentistry. What more could you ask for in a podcast? SO have a listen, read the free PDFs below, and you too could save a life or at least relieve your friend’s dental pain with some stone tools.

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The final nail in the Paxlovid coffin?

Butler CC, Pinto AD, Harris V, Holmes J, Rahman NM, Cureton L, Hayward G, Richards DB, Lowe DM, Standing JF, Breuer J, Hood K, Png ME, Petrou S, Dorward J, Patel MG, Thomas NPB, Evans P, Hart ND, Jani BD, Hosseini B, Murthy S, McBrien K, Condon A, McDonald EG, Daley P, Greiver M, da Costa BR, Selby P, Jüni P, Lee TC, Shi H, Detry MA, Saunders CT, Fitzgerald M, Berry NS, Saville BR, Khoo SH, Nguyen-Van-Tam JS, Hobbs FDR, Yu LM, Little P; PANORAMIC Trial and CanTreatCOVID Trial Collaborative Groups. Oral Nirmatrelvir-Ritonavir for Covid-19 in Higher-Risk Outpatients. N Engl J Med. 2026 Apr 23;394(16):1583-1594. doi: 10.1056/NEJMoa2502457. PMID: 42019019

This paper actually describes two separate open-label adaptive platform RCTs: PANORAMIC out of the UK and CanTreatCOVID out of Canada. The trials are pretty similar. If you want the full details you can read Justin’s full rant on here.

Bottom line: Maybe Paxlovid should join Tamiflu on the shelves of the medical misadventure museum?

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Minocycline, for stroke?

Lu Y, Guan L, Wu J, Yang Q, Zhang M, Zhou D, Yang H, Pan Y, Wang L, Qiu B, Liu C, Wang Y, Yang Y, Zhou X, Qu H, Liao X, Liu L, Zhao X, Bath PM, Johnston SC, Amarenco P, Turc G, Shi FD, Wang Y, Wang Y; EMPHASIS Investigators. Efficacy and safety of minocycline in patients with acute ischaemic stroke (EMPHASIS): a multicentre, double-blind, randomised controlled trial. Lancet. 2026 Feb 14;407(10529):679-688. doi: 10.1016/S0140-6736(25)01862-8. Epub 2026 Jan 30. PMID: 41628627

So, now acne medication has about the same level of evidence for acute stroke as does tPA?

Bottom line: In this high quality double-blind RCT, minocycline improved functional outcomes from ischemic stroke. 

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They are still trying to make recombinant factor VII a thing??

Broderick JP, Naidech AM, Elm JJ, Toyoda K, Dowlatshahi D, Demchuk AM, Khatri P, Steiner T, Bath PM, Audebert HJ, Vagal A, Yoshimura S, Mayer SA, Wang LL, Sabagha N, Mocco JD, Molina C, Aviv R, Stinson E, Quadri SA, Carrozzella J, Huynh T, Phan A, Beall J, Davis I, Sakai N, Ohta T, Yokosawa M, Hara T, Sangha N, Morita K, Dominc Tse MY, Streib CD, Miyashita F, Silva Y, Nagakane Y, Gheorghiu T, Sun CH, Hirano T, Poli S, Izumo T, Fukuda-Doi M, Ihara M, Koga M, Buck B, Walsh KB, Spokovny I, Grotta JC; FASTEST Investigators. Recombinant factor VIIa versus placebo for spontaneous intracerebral haemorrhage within 2 h of symptom onset (FASTEST): a multicentre, double-blind, randomised, placebo-controlled, phase 3 trial. Lancet. 2026 Feb 21;407(10530):773-783. doi: 10.1016/S0140-6736(26)00097-8. Epub 2026 Feb 4. PMID: 41653933

Recombinant factor VIIa seems like a great idea in principle, yet we know that is rarely one that translates into real world benefits…

Bottom line: An expensive drug that probably does nothing and may cause harm. Sounds like something we should avoid but probably won’t!

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Strike 2 for whole blood

Sperry JL, Guyette FX, Cotton BA, Luther JF, Utarnachitt RB, Kutcher ME, Daley BJ, Peetz AB, Patel MB, Goodman MD, Claridge JA, Patel N, Harbrecht BG, Hashmi ZG, Zarychanski R, Neal MD, Yazer MH, Martin-Gill C, Vincent LE, Harner AM, Meyer DE, Latimer AJ, Robinson BR, McKnight CL, Hinckley WR, Miller KR, Jansen JO, Martin D, Fox EE, Rosario-Rivera BL, Wisniewski SR; TOWAR Study Group. Prehospital Resuscitation with Type O Whole Blood for Trauma and Hemorrhage. N Engl J Med. 2026 May 18. doi: 10.1056/NEJMoa2602167. PMID: 42150044

Last episode we looked at the SWIFT trial out the UK which was asking the same question and came up negative. So this new trail from the United States (that’s the country just below Canada on a map) is more data that keeps our Bayesian needle exactly in the same place… meh!

Bottom line: It is not unexpected, but this cluster RCT shows no benefit from whole blood, and the point estimate is a major red flag. 

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HI-PEITHO – widely misunderstood

Rosenfield K, Klok FA, Piazza G, Sharp ASP, Ní Áinle F, Jaff MR, Barco S, Goldhaber SZ, Kucher N, Lang IM, Schmidtmann I, Sterling KM, Araszkiewicz A, Arora V, Cires-Drouet R, Coghlan J, Hobohm L, Ito WD, Jacobson K, Kaiser C, Kopec G, Marx K, McElwee S, Meneveau N, Monteleone P, Montero-Cabezas JM, Olivier CB, Park J, Roik M, Sakhuja R, Tego A, Theurl M, Visveswaran G, Vos JA, Young MN, Asch FM, Konstantinides SV; HI-PEITHO Investigators. Ultrasound-Facilitated, Catheter-Directed Fibrinolysis for Acute Pulmonary Embolism. N Engl J Med. 2026 Mar 28. doi: 10.1056/NEJMoa2516567. PMID: 41910345

We have heard a lot from the interventional folk about invasive devices for the management of biggish PEs in recent times. I wrote an overview earlier this year.

(You can listen to Weingart and Justin argue about HI-PEITHO over on EmCrit.) It is a fun chat between a polite American and a ranty Canadian (i.e. equally polite…)

Bottom line: Despite widely being discussed as a positive trial, there were no real differences – peripheral IV tPA is probably still the more available and reliable treatment option.

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So should we be aggressive with clots in the legs instead?

Vedantham S, Kahn SR, Marston WA, Weinberg I, Sista AK, Magnuson EA, Cohen DJ, Wasan SM, Razavi MK, Goldhaber SZ, Sanfilippo KM, Comerota AJ, Azene EM, Chaar CIO, Leung DA, Kolli KP, Kalva SP, Rostambeigi N, Desai A, Desai KR, Tafur AJ, Khalsa B, Majerus E, Wang B, Wang Y, Nieters P, Derfler MC, Oliver A, Hardy C, Bashir R, Winokur R, Weger N, Khaja MS, Sharma A, Mani N, Kavali P, Thukral S, Lake LL, Mikkelsen K, Parpia S; C-TRACT Trial Investigators. Endovascular Therapy for Post-Thrombotic Syndrome – A Randomized Trial. N Engl J Med. 2026 Apr 13:10.1056/NEJMoa2519001. doi: 10.1056/NEJMoa2519001. PMID: 41972998

Bottom line: Fractional benefits and possible harms… not really a fair fight as one group got dual anticoags. But good to know what is on offer for our chronic post DVT patients.

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The dose of iodinated contrast required for a CT scan is below the toxicological threshold of concern for nephrotoxicity

Phillips A, Blumenberg A. The dose of iodinated contrast required for a CT scan is below the toxicological threshold of concern for nephrotoxicity: a toxicological perspective. JEM Rep. 2026 Jun;5(2). doi: 10.1016/j.jemrpt.2026.100220

The best evidence that we have tells us that CT contrast simply does not cause kidney injury.

This is an interesting Toxicological perspective on the debate about AKI due to contrast.

Short answer: for diagnostic CT studies we are well below the “Threshold of Toxicologic Concern.” Carry on and contrast.

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Yes, peripheral pressors are safe

Greaves RL, Quay A, Bolot R, King J, Gibbs C. Safety of Peripheral Vasoactive Drug Administration in Prehospital and Retrieval Medicine (SPOTLESS-2): A Prospective Observational Cohort Study. Acad Emerg Med. 2026 Apr;33(4):e70271. doi: 10.1111/acem.70271. PMID: 41947342

This is one of my passion projects… the safety and efficacy of peripheral vasopressors can make a big difference to rural Resus patients. This data out of Queensland supports all of my biases and backs up my beliefs!

Bottom line: Peripheral vasopressors are safe to use, and considering the harms of central lines, are honestly the preferred option for early resuscitation in almost all patients. 

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Diagnostic accuracy of tongue coating in identifying acute appendicitis

Mori H, Yamasaki K, Saishoji Y, Torisu Y, Mori T, Nagai Y, Izumi Y. Diagnostic accuracy of tongue coating in identifying acute appendicitis: a prospective cohort study. Emerg Med J. 2025 Jul 22;42(8):519-525. doi: 10.1136/emermed-2024-214210. PMID: 40169241

The TCI (Tongue Coating Index) is probably about as useful as any other clinical decision score in acute appendicitis. It is very cheap and fast, so why not have a look. Worst case scenario is second-hand halitosis?

I will leave it up to you to decide whether that is because the tongue coating index is valuable, or because most of the clinical decision rules in existence are absolute garbage and are probably making you worse at your job.

Justin says he will buy a pint for anyone who calls a surgeon without imaging and tries to convince them that there is an acute appendicitis based primarily on your tongue exam. Challenge accepted.

Bottom line: Glossal Gestalt for the win?

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Neanderthal Dentistry – how hard can it be?

Zubova AV, Zotkina LV, Olsen JW, Kulkov AM, Moiseyev VG, Malyutina AA, Davydov RV, Markin SV, Maksimovskiy EA, Chistyakov PV, Krivoshapkin AI, Kolobova KA. Earliest evidence for invasive mitigation of dental caries by Neanderthals. PLoS One. 2026 May 13;21(5):e0347662. doi: 10.1371/journal.pone.0347662. Erratum in: PLoS One. 2026 Jun 5;21(6):e0351227. doi: 10.1371/journal.pone.0351227. PMID: 42127021

A fascinating insight into the culture of our Neanderthal cousins – they were likely doing dentistry – planning, making tools and carrying out prolonged procedures in Siberia nearly 60,000 years ago

Given the relative unavailability of acute dental services in most rural places in the world – it is a relief to know that our ancient cousins managed to do this sans anaesthesia with some rock tools. Much cheaper if you have the will power and pain tolerance.

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