Saturday, March 29, 2014

Global Emergency Medicine Journal Club: Social Media Responses to the November 2013 Annals of Emergency Medicine Journal Club.

The Annals November 2013 Journal Club issue marked one of the first collaborations with Academic Life in Emergency Medicine, a medical education blog, in an effort to promote a worldwide, transparent, online effort to perform critical appraisals of journal articles. The Global Emergency Medicine Journal Club was hosted on the blog for 1 week during November 18 to 24, 2013, with comments moderated on the blog and on Twitter. This summary article compiles the discussion and insights.

Ann Emerg Med. 2014 Apr;63(4):490-4

Friday, March 21, 2014

RADIOLOGY JOURNAL CLUB: Is screening MRI indicated for women with a personal history of breast cancer?

OBJECTIVE: American College of Radiology and Society of Breast Imaging guidelines call for routine breast MRI screening only for women with the highest risk profiles for development of breast cancer, suggesting that screening of women at lower risk might result in an increased frequency of false-positive biopsy results. The purpose of this study was to test this assumption by comparing MRI-guided biopsy outcomes of lesions detected at MRI screening of women with a personal history of breast cancer with outcomes among women with genetic or familial high risk.

MATERIALS AND METHODS: Outcomes of 130 MRI-guided biopsies were analyzed. One group consisted of women with hereditary (genetic or familial) risk, and the other group consisted of women with a personal history of breast cancer. Biopsies were performed with a 9-gauge vacuum-assisted device or surgically after MRI localization.

RESULTS: Of 130 MRI-guided biopsies, 20 (15%) yielded malignant histologic findings, 14 (11%) yielded high-risk lesions, and 96 (74%) had benign findings. There was a slightly higher malignancy rate for the personal-risk group (19%) compared with the hereditary-risk group (13.5%). There also was a slightly higher combined rate of malignancy and high-risk lesions (34% vs 22%) with no statistically significant difference (p < 0.25, p < 0.12). Patients in the hereditary-risk group were younger (44 ± 1.2 vs 54 ± 1.7 years; p < 0.001) than those in the personal-risk group.

CONCLUSION: Our preliminary data show no difference between the two risk groups with respect to probability of an MRI-guided biopsy result of malignancy, calling into question the proposed assumption. Further prospective studies of the role of MRI screening combined with MRI-guided biopsy when required for patients with previously treated localized breast cancer may be indicated.

AJR Am J Roentgenol. 2013 Oct;201(4):919-27

Wednesday, March 19, 2014

JOURNAL CLUB: CT dose optimization for whole-body PET/CT examinations.

OBJECTIVE. The objective of this study was to optimize CT protocols for whole-body PET/CT

MATERIALS AND METHODS. Effective dose from the CT component of the examination was estimated using dose-length product (DLP) values from reports generated by the scanner and anatomy-specific conversion factors. Twenty-six patients who underwent studies before and after the optimization were included in an analysis of image quality. The studies were randomized and blinded for an experienced PET and CT reader who graded the imaging quality of anatomic structures.

RESULTS. CT protocol optimization resulted in a 32% reduction of the mean CT radiation dose: The mean effective dose was reduced from 8.1 to 5.5 mSv. The blinded analysis of image quality showed no clinically significant degradation of the lower-dose studies.

CONCLUSION. The results of this study showed that optimization of CT acquisition can effectively reduce radiation dose in a whole-body PET/CT examination without significantly sacrificing image quality.

AJR Am J Roentgenol. 2013 Aug;201(2):257-63

Monday, March 17, 2014

Journal Club Article: Azithromycin and Levofloxacin Use and Increased Risk of Cardiac Arrhythmia and Death

TITLE: Azithromycin and Levofloxacin Use and Increased Risk of Cardiac Arrhythmia and Death

CITATION:  Ann Fam Med. 2014 Mar-Apr;12(2):121-7

FULL TEXT LINK:  http://goo.gl/nBJE2c

Q1: In order to compare the side-effects of the antibiotics against one another, we need to ensure that the patient groups are similar. Are they? #pcmjc

Q2: In your practice, are you more likely to prescribe amoxicillin to patients that are less ill, and azithromycin to more ill patients? #pcmjc

Q3: Was the author's statistical handling of confounding variables legitimate? http://bit.ly/OprrBN #pcmjc

Q4: Even though the authors corrected for confounding variables, does this mean that the sicker patients should get amoxicillin instead of levofloxacin? #pcmjc

Q5: Will this article change your practice? Why or why not?  #pcmjc

Thursday, March 13, 2014

Journal club for faculty or residents: a model for lifelong learning and maintenance of certification.

The journal club offers a model for lifelong learning and maintenance of certification (MOC) for residents and faculty staff.
  • First, it sharpens participants' critical appraisal skills by providing a space to discuss relevant medical literature. 
  • Second, it motivates participants to seek new medical literature on their own using technology. 
Our model sets forth a four-year journal club curriculum that could be used as one continuous curriculum or in bits and pieces:
  • In the first year, the focus is teaching residents how to read an article. 
  • The second year focuses on what is of interests to the reader. 
  • The third year applies the resident's appraisal skills to assigned articles to test whether they can determine which have reliable and valid findings and which are flawed. 
  • In the fourth year residents are asked to distinguish whether articles are well researched and referenced. 
Our model also motivates participants to read articles in faculty journal clubs throughout their career. In most academic settings category 1 continuing medical education (CME) credits can be awarded so journal club can have the added benefit of satisfying maintenance of certification CME credits. From journal club both residents and faculty can learn what is new and learn to apply this new information in their practice. Finally, because technology creates an overabundance of relevant medical literature, participants using our model can develop strong critical appraisal skills and methods for organizing the information they find that make this information readily available for future use and retrieval.

Int Rev Psychiatry. 2013 Jun;25(3):276-83

Wednesday, March 12, 2014

Exploring the individual determinants of evidence uptake in allied health using a journal club as a medium.

Exploring the individual determinants of evidence uptake in allied health using a journal club as a medium.
Adv Med Educ Pract. 2013;4:43-53
Authors: Lizarondo L, Grimmer K, Kumar S

PURPOSE: A recent trial which examined the impact of a structured model of journal club (JC) demonstrated variability in evidence-based practice (EBP) outcomes across allied health disciplines. The aim of the current study was to determine if there are individual practitioner characteristics that could explain this variability and identify potential predictors of EBP outcomes.
METHOD: This exploratory study used the data obtained from the JC trial. The predictive value of practitioner-related variables including academic degree, previous exposure to EBP training, and previous research involvement was analyzed using univariate logistic regression models. The dose of intervention was also included in the exploratory analysis.
RESULTS: The change in self-reported knowledge, evidence uptake, and attitude following participation in a JC was influenced by individual practitioner characteristics including their discipline, academic background, previous EBP training, previous research involvement, and JC attendance. Improvement in objective knowledge did not seem to be affected by any of these variables. Whether these individual characteristics have the ability to predict who will achieve less than, or greater than, 50% change in knowledge, attitude, and evidence uptake, is not known, except for academic background which predicted physiotherapists' improvement in attitude.
CONCLUSION: Participation in a structured JC can lead to significant improvements in EBP knowledge irrespective of the characteristics of individual practitioners. The change in attitude and evidence uptake, however, may be influenced by individual characteristics which will therefore require careful consideration when designing EBP interventions. An EBP intervention is likely to be successful if a systematic assessment of the barriers at different levels (ie, individual, organizational, and contextual) informs the choice of evidence implementation strategy.

23745100 [PubMed]
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Monday, March 10, 2014

Implementing a successful journal club in an anesthesiology residency program.

Implementing a successful journal club in an anesthesiology residency program.
F1000Res. 2013;2:15
Authors: Pitner ND, Fox CA, Riess ML

Journal clubs are an integral element of residency training. We report the successful implementation of a monthly structured journal club in our anesthesia residency program. Based on resident surveys before and one year after its start, the journal club led to a significantly higher confidence in how to critically appraise literature and present a manuscript. The journal club also improved the residents' ability to search the literature and their statistical knowledge, skills that are essential in the practice of evidence-based medicine. We describe key features that may aid other training programs in organizing a stimulating an educational and sustainable journal club.

24358844 [PubMed]
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JOURNAL CLUB: Neglecting to Screen Women Between 40 and 49 Years Old With Mammography: What Is the Impact on Treatment Morbidity and Potential Risk Reduction?


JOURNAL CLUB: Neglecting to Screen Women Between 40 and 49 Years Old With Mammography: What Is the Impact on Treatment Morbidity and Potential Risk Reduction?
AJR Am J Roentgenol. 2014 Feb;202(2):282-8
Authors: Plecha D, Salem N, Kremer M, Pham R, Downs-Holmes C, Sattar A, Lyons J

OBJECTIVE. The purpose of this study is to determine whether there were significant differences with respect to treatment recommendations, stage at diagnosis, and identification of high-risk lesions for women 40-49 years old undergoing screening mammography (screened) compared to women with a symptom needing a diagnostic evaluation (nonscreened). MATERIALS AND METHODS. We reviewed the pathology results of all imaging-guided biopsies performed at the three breast center locations of University Hospitals Case Medical Center from January 1, 2008, to December 31, 2011. In patients diagnosed with a high-risk lesion or breast cancer, the reason for presentation, pathology, tumor size, stage, receptor characteristics, and treatment were recorded. The chi-square test was used for statistical analysis. RESULTS. Of 230 primary breast cancers, 149 were in the screened group and 81 were considered nonscreened. Nonscreened patients were more likely to undergo chemotherapy (p = 0.042). Eighty-one percent of the high-risk lesions were diagnosed in the screened patients. Screened patients with cancer were significantly more likely to receive a diagnosis at earlier stages (p = 0.001), to have negative axillary lymph nodes (p = 0.005), and to have smaller tumors (p < 0.001). CONCLUSION. In addition to the benefits of receiving a diagnosis at earlier stages, with smaller tumors and node negativity, patients with breast cancer undergoing screening mammography aged 40-49 years are less likely to require chemotherapy and its associated morbidities. The majority of high-risk lesions were diagnosed in the screened group, which may lead to the benefit of chemoprevention, lowering their risk of subsequent breast cancer, or screening with MRI, which may diagnose future mammographically occult malignancies.

24450666
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Sunday, March 9, 2014

JOURNAL CLUB: Comparison of Assessment of Preoperative Pulmonary Vasculature in Patients With Non-Small Cell Lung Cancer by Non-Contrast- and 4D Contrast-Enhanced 3-T MR Angiography and Contrast-Enhanced 64-MDCT.


JOURNAL CLUB: Comparison of Assessment of Preoperative Pulmonary Vasculature in Patients With Non-Small Cell Lung Cancer by Non-Contrast- and 4D Contrast-Enhanced 3-T MR Angiography and Contrast-Enhanced 64-MDCT.
AJR Am J Roentgenol. 2014 Mar;202(3):493-506
Authors: Ohno Y, Nishio M, Koyama H, Yoshikawa T, Matsumoto S, Seki S, Sugimura K

OBJECTIVE. The purpose of this article is to prospectively and directly compare the capabilities of non-contrast-enhanced MR angiography (MRA), 4D contrast-enhanced MRA, and contrast-enhanced MDCT for assessing pulmonary vasculature in patients with non-small cell lung cancer (NSCLC) before surgical treatment.

SUBJECTS AND METHODS. A total of 77 consecutive patients (41 men and 36 women; mean age, 71 years) with pathologically proven and clinically assessed stage I NSCLC underwent thin-section contrast-enhanced MDCT, non-contrast-enhanced and contrast-enhanced MRA, and surgical treatment. The capability for anomaly assessment of the three methods was independently evaluated by two reviewers using a 5-point visual scoring system, and final assessment for each patient was made by consensus of the two readers. Interobserver agreement for pulmonary arterial and venous assessment was evaluated with the kappa statistic. Then, sensitivity, specificity, and accuracy for the detection of anomalies were directly compared among the three methods by use of the McNemar test.

RESULTS. Interobserver agreement for pulmonary artery and vein assessment was substantial or almost perfect (κ = 0.72-0.86). For pulmonary arterial and venous variation assessment, there were no significant differences in sensitivity, specificity, and accuracy among non-contrast-enhanced MRA (pulmonary arteries: sensitivity, 77.1%; specificity, 97.4%; accuracy, 87.7%; pulmonary veins: sensitivity, 50%; specificity, 98.5%; accuracy, 93.2%), 4D contrast-enhanced MRA (pulmonary arteries: sensitivity, 77.1%; specificity, 97.4%; accuracy, 87.7%; pulmonary veins: sensitivity, 62.5%; specificity, 100.0%; accuracy, 95.9%), and thin-section contrast-enhanced MDCT (pulmonary arteries: sensitivity, 91.4%; specificity, 89.5%; accuracy, 90.4%; pulmonary veins: sensitivity, 50%; specificity, 100.0%; accuracy, 95.9%) (p > 0.05).

CONCLUSION. Pulmonary vascular assessment of patients with NSCLC before surgical resection by non-contrast-enhanced MRA can be considered equivalent to that by 4D contrast-enhanced MRA and contrast-enhanced MDCT.

24555585
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Friday, March 7, 2014

Journal Club: Comparison of symptomatic and asymptomatic persons with Alzheimer disease neuropathology.

Journal Club: Comparison of symptomatic and asymptomatic persons with Alzheimer disease neuropathology.
Neurology. 2014 Mar 4;82(9):e76-8
Authors: Brosch JR, Matthews BR

Advances in neuroimaging, biomarkers, and clinical data have led to the hypothesis that the pathologic process of Alzheimer dementia begins decades prior to functional decline and diagnosis.(1-3) High-profile clinical trial results have shown that biomarker changes can be made via pharmacologic intervention; however, the timing of this intervention has likely been too late to impact the cascade of neurodegenerative changes.(4,5) In "Comparison of symptomatic and asymptomatic persons with Alzheimer disease neuropathology" by Monsell et al.,(6) neuropathologic and clinical data were used to determine the risk of developing clinically significant cognitive impairment. This work represents a significant contribution because it examines a large cohort of autopsy data, which includes patients with Alzheimer dementia neuropathology who were clinically normal or diagnosed with mild cognitive impairment and Alzheimer-type dementia. The authors report a 3-fold increase in the risk of cognitive symptoms in association with quantifiable increases in neurofibrillary tangle pathology. Additionally, several other factors including APOE gene status, history of depression, and age impacted the clinical presentation. The ultimate goal of this investigation and similar studies is to facilitate the early and accurate identification of those at risk of developing Alzheimer dementia, such that potentially disease-modifying therapies may be considered.

24590252
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Monday, March 3, 2014

Journal Club: Change in mental health after smoking cessation

The latest journal club article is "Change in mental health after smoking cessation" http://bit.ly/NGZvc5

To join the discussion, use the Twitter hashtag

Q1: how confident are you in the conclusion of this meta-analysis? Are meta-analysis studies reliable in this research area? #pcmjc

Q2: If smoking cessation results in as good an improvement in depression as do the SSRI medications, should SSRI medications ever be prescribed to smokers? Or should we prescribe nicotine patches instead? #pcmjc

Q3: Should mental health facilities allow patients to smoke? What about prisons? 

Q4: What public health measures can be taken to decrease smoking rates around the world?

Q5: Since television advertisements for cigarettes have been banned, should movies still be allowed to have actors smoke cigarettes? Aren't these actors being forced to compromise their own health, as well as the health of the viewers?