Can't Miss Articles for Interns

[Walfredo]

Anyone have suggestions of top EM related articles that all interns should have working knowledge of? I'm a fourth-yr awaiting match and taking plenty of time to enjoy myself (read: I'm having fun, so don't need the reflective "take it easy in fourth year" reply), but looking for some relevant reading prior to starting residency. I'm thinking along the lines of EGDTS, PERC, C-spine Clearance, etc., so if you are or have been a resident, your thoughts are appreciated...

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[The White Coat Investor]

Anyone have suggestions of top EM related articles that all interns should have working knowledge of? I'm a fourth-yr awaiting match and taking plenty of time to enjoy myself (read: I'm having fun, so don't need the reflective "take it easy in fourth year" reply), but looking for some relevant reading prior to starting residency. I'm thinking along the lines of EGDTS, PERC, C-spine Clearance, etc., so if you are or have been a resident, your thoughts are appreciated...

NEXUS is good. Something on PE is important, but I'm not sure which would be the BEST article to read. Something on A-fib, maybe this:

http://emergency-medicine.jwatch.org/cgi/content/full/2010/702/1

I'd probably look at something on ACS too. And something on TPA in stroke. Perhaps this: http://emergency-medicine.jwatch.org/cgi/content/full/2010/827/1

 

[RxnMan]

There are a number of papers listed in the FAQ via "My so there file" and the Colorado Compendium.

 

[xaelia]

And something on TPA in stroke. Perhaps this: http://emergency-medicine.jwatch.org/cgi/content/full/2010/827/1

Only if you're going to cite it in the context that we've been misled by thieves regarding rTPA in stroke.

 

[RxnMan]

Only if you're going to cite it in the context that we've been misled by thieves regarding rTPA in stroke.

I keep hearing two sides. I was just on my neuro rotation, and they wanted to give it right and left. A few on the EM board say we shouldn't. Can you give me a few the citations you're basing your opinion on? I've (briefly) looked in the past and haven't seen anything that supports a statement like the quote above.

 

[xaelia]

I keep hearing two sides. I was just on my neuro rotation, and they wanted to give it right and left. A few on the EM board say we shouldn't. Can you give me a few the citations you're basing your opinion on?

http://www.thennt.com/thrombolytics-for-stroke

Is one summary of an opinion regarding the quality of evidence for stroke. It's not my favorite argument against rTPA, but it's a quick review of how many studies regarding rTPA were actually negative.

My beef is more with the specific articles from NINDS (Part 1, stopped early for no benefit and protocol violations, clinically significant differences between the groups) and ECASS III (clinically significant differences between the groups). You shouldn't be treating hundreds of thousands of patients based on these two small studies.

The thieves portion of my comment comes from, for example, ECASS III was sponsored by the manufacturer, authors were paid consultants, receiving honoraria, and receiving grant funding from the manufacturer, and some authors are actually employees of the manufacturer.

 

[RxnMan]

Thanks for the link.

I don't think industry involvement necessarily makes a study worthless (I am willing to move this discussion elsewhere so that this thread doesn't get hijacked further). Nearly all of the drug trials in this country are funded by industry. The vast majority of academics and scientific institutions see themselves as the discoverers of basic science information that is "handed off" to industry for development. Then I'm taught in class I can't trust anything coming from industry. We can't have it both ways.

Rules have to be set up in advance. e.g. mandatory reporting of data, regardless of outcome (though this is becoming more standard with the NIH Clinical Trials db), transparency, investigators not having a stake in the drug outcome, study finances being handled by a neutral 3rd party, etc. As long as these ethical guidelines are adhered to, there should be no problem with a company funding a drug trial. Patients deserve improved care, and this is how we test new and better treatments.

In the interest of collegiality, I would also have few problems with their scientific rep (likely a PhD, who would have a hand in developing the drug, writing the paper, etc.) being named on the paper. Again, this all goes out the window if anyone breaks the rules (e.g. tries to write something the data doesn't support).

But being paid honoraria is a no-no.

 

[pseudoknot]

Nearly all of the drug trials in this country are funded by industry. ... Then I'm taught in class I can't trust anything coming from industry. We can't have it both ways.

We can, if we just accept that we don't have very much reliable information about anything in medicine.

You know how people think scientists are always changing their minds and there's a study to support every side of an issue? It's because most of the literature consists of rigged industry studies and observational data that we then treat as fact.

 

[RxnMan]

We can, if we just accept that we don't have very much reliable information about anything in medicine...

I agree with the latter, but not the former. We don't have much reliable/highly rigorous/definitive/etc info because clinical research examines the most difficult subject - humans. Clinical research is too difficult, dangerous, and expensive to have definitive answers on every possible subject. There has to be some element of interpretation and extrapolation to the patient.

...You know how people think scientists are always changing their minds and there's a study to support every side of an issue? It's because most of the literature consists of rigged industry studies and observational data that we then treat as fact.

Well, now you're arguing a different point. Results of preliminary trials are often conflicting because they usually have small n's (more open to random effects), study different patient populations, and are of varying quality. Despite these disadvantages, we live in a world of limited resources, so it is sensible that we conduct multiple small-scale studies (in all fields, not just drug trials) before launching the expensive definitive large study.

Ideas and theories will always evolve as new data informs the field, and science is ultimately self-correcting. That is why transparency and the NIH Clinical Trials db is so important - it overcomes the publication bias of negative studies. (There is also the bias towards frequentist statistics, when we should be going towards a Bayesian approach. )

Another reason why the public think scientists vacillate is because of the media's bias towards promoting the most sensational aspect or interpretation of a study, regardless of what a study actually finds. Science reporters, many of whom do not have science degrees, also tend to take the latest study as being the most definitive, instead of putting a new study in context of the literature. This is all understandable, given their need to sell papers.

 

[pseudoknot]

RxnMan, I agree completely with everything you said, except it's not just science reporters and the public that interpret this stuff uncritically. Physicians are not scientists, not most of them, and in my experience they tend to treat the distinction between correlation and causation as some sort of obscure technicality.

And yes, we're not going to have definitive answers to most questions in the foreseeable future, unless the scientific paradigm changes somehow. Medicine is too complex, even RCTs have huge limitations and we can't do them for everything.

 

[RxnMan]

RxnMan, I agree completely with everything you said, except it's not just science reporters and the public that interpret this stuff uncritically. Physicians are not scientists, not most of them, and in my experience they tend to treat the distinction between correlation and causation as some sort of obscure technicality...

Then, I guess it's good that you'll be there to show your colleagues how it's done, right?

OP - I almost forgot. Try looking up the Rational Clinical examination series by the NEJM. Some are a little old, and others aren't EM related, but there's good ones like "Does this patient have meningitis?" or "Does this patient have an MI?".

 

[Xerxes1729]

I'll second the Rational Clinical Exam series.

 

[Walfredo]

Thanks for the tips all... Just in case anyone else is curious and doesn't want to dig, here are direct links to

"So There" Thread and Colorado Compendium

also appreciate the OT discourse, keeps us fresh in thinking about the regimens we use everyday and how these protocol are developed.