The Skeptics Guide to Emergency Medicine

Dr. Salim R. Rezaie, a community emergency physician and founder of REBEL EM, joins the discussion on the controversial role of Vitamin C in treating sepsis. They critically analyze a troubling case study involving a 59-year-old woman and delve into the study methodology, discussing the importance of evidence-based medicine. The conversation highlights the potential risks and mortality linked to Vitamin C therapy, urging caution in its use. Salim emphasizes the need for rigorous trials to ensure patient safety and effective treatment.

Date: July 1st, 2022 Guest Skeptic: Dr. Ravi Garg is a Neurologist in the Department of Neurology, Division of Neurocritical Care at Loyola University Chicago. Reference: Garg R, Mickenautsch S. Risk of selection bias assessment in the NINDS rt-PA stroke study. BMC Med Res Methodol. 2022 Jun 15;22(1):172. This is an SGEM Xtra episode. Dr. Garg saw some tweets about the NINDS trial and sent me his recent publication. I asked him to come on the SGEM and discuss the original NINDS trial, some of the reanalyses and share his analysis of the NINDS data. One of the criticisms of Emergency Medicine physicians who have done FOAMed post publication reviews of the stroke literature like Dr. Justin Morgenstern, Dr. Ryan Radecki, Dr. Anand Swaminathan and Dr. Salim Razaie, is that we are not neurologists and specifically not stroke neurologists. While this is true, we are part of the team that diagnose and treat acute stroke patients. The SGEM tries to include a wide variety of clinicians in this knowledge translation project. Great emergency care takes a team from the prehospital setting, emergency department, inpatient and outpatient all working together. That is why we have had paramedics, nurses, physiotherapists, pharmacists and a wide spectrum of physician specialists on the SGEM. However, until now have we not had a neurologist on the SGEM who has a specialized interest in stroke neurology and published on thrombolysis as a guest skeptic. Dr. Garg sent me his analysis of the NINDS trial that he wrote with his co-author Dr. Steffen Mickenautsch. This new peer reviewed publication is the basis of this SGEM Xtra episode. The NINDS trial was published back in 1995 and we did a structured critical appraisal of the classic paper with Dr. Anand Swaminathan on SGEM#70.  I was a resident at the time of publication and Dr. Garg was only eight years old. Dr. Garg was asked a series of questions. You can listen to his responses on the SGEM podcast. Thoughts on the NINDS Trial and Some of the Reanalyses Dr. Ravi Garg Any general thoughts about NINDS trial? One concern about the NINDS trial was the baseline differences in NIHSS score. This resulted in multiple reanalyzes attempting to control for these factors. NINDS commissioned an independent committee to investigate if any of these imbalances invalidated the entire trial. This committee’s findings supported the use of tPA in less than three hours (Ingall et al 2004). What are your thoughts on this commissioned report? Another reanalysis was done by Kwiatkowski et al 2005 that also confirmed that the baseline imbalance in the NINDS trial did not account for the better outcome of tPA-treated patients. Any brief comments on this reanalysis? Hoffman and Schrieger stirred things up a bit with their graphic reanalysis of the NINDS trial using the NIHSS score. They published their findings in Annals of EM 2009. The results questioned the effect of tPA for acute ischemic stroke in patients treated within three hours. The graphs created in the publication also failed to support the "time-is-brain" hypothesis. There are some criticisms of this graphic reanalysis. What are your thoughts on this contrarian view? Saver et al responded to Hoffman and Schrieger’s graphic reanalysis in Academic Emergency Medicine 2010. They pointed out number concerns with the publications. Did Saver and colleagues make some sound arguments? Ravi Garg and Steffen Mickenautsch BMC June 2022 The title of your paper is Risk of selection bias assessment in the NINDS rt-PA stroke study. It was published in BMC Medical Research Methodology, June 2022. With all the other reanalyses, what motivated you to do this another reanalysis of the NINDS trial? You were able to get patient level data for this review. Why is that important? What tool did you use to assess the NINDS trial for risk of selection bias?

Date: June 30th, 2022 Reference: McGinnis et al. Major adverse cardiac event rates in moderate-risk patients: Does prior coronary disease matter? AEM June 2022. Guest Skeptic: Dr. Corey Heitz is an emergency physician in Roanoke, Virginia. He is also the CME editor for Academic Emergency Medicine. Case: You are working a shift in your local community emergency department (ED) when a 47-year-old male presents with chest pain. His symptoms are moderately suspicious, he has a normal EKG, and a history of hypertension. His father had a minor heart attack at the age of 63. With a negative initial troponin, this gives him a HEART score of 4. He has no history of coronary artery disease. You have been reading about the overuse of objective cardiac testing (OCT) and wonder if this patient really needs admission to the hospital. Background: Chest pain is one of the most common presentations to the ED. Much ink has been spilled over the years on trying to find a way to safely rule-out acute coronary syndrome in these patients. Multiple clinical decision instruments have been created to risk stratify patients and guide clinicians (TIMI, GRACE, MAC, T-MAC, HE-MAC, ADAPT, VCPR, EDACS, etc). The HEART score was originally developed in 122 patients in the Netherlands and published in 2008. Backus and colleagues published their multi-centre validation of the HEART score in 2010. Since then, there have been several studies looking at this clinical decision instrument. We looked at a HEART Score Pathway that included a HEART Score and 0 and 3 hour cardiac troponin testing on SGEM#151 with our friend Salim Rezaie. The bottom line from that episode was that the HEART Pathway appears to have the potential to safely decrease objective cardiac testing, increase early discharge rates and cut median length of stay in low-risk chest pain patients presenting to the ED with suspicion of ACS. In prior decades nearly all patients presenting to EDs with chest pain were admitted to hospital. If we thought about ACS, we brought them in. This would be for objective cardiac testing including stress test, CT-angiography, and/or invasive angiography. However, all this recent research into clinical decision tools and pathways to risk-stratify these patients is reducing admissions and therefore ED and hospital overcrowding [1-5]. Many patients risk stratified as “non-low” risk are admitted, but the benefit of objective cardiac testing in this cohort is unclear in the absence of elevated troponins or abnormal EKGs [6-9]. The study we will be reviewing today seeks asks if the presence of known coronary artery disease is predictive of major adverse cardiac events (MACE) in a previously identified non-low risk group of patients. Clinical Question: What is the 30-day incidence of MACE in patients who are non-low risk but have known coronary artery disease? Reference: McGinnis et al. Major adverse cardiac event rates in moderate-risk patients: Does prior coronary disease matter? AEM June 2022. Population: Adult patients (age >21 years) with chest pain or suspected ACS, HEAR >4, elevated troponin, ischemic EKG or prior CAD Exclusions: Patients with evidence of an ST-segment elevated myocardial infarction and patients who were identified as low risk (HEAR < 4) by the HEART Pathway Intervention: Assessment of moderate-risk patients as described in the inclusion/exclusion criteria Comparison: None Outcome: Primary Outcome: 30-day MACE defined as the composite of all-cause death, MI, or coronary revascularization. Secondary Outcomes: Individual components of the MACE composite at the index visit Study Design: A preplanned subgroup analysis of non–low-risk patients in the HEART Pathway Implementation Study was conducted. The original study was a prospective interrupted time-series of accrued adults with possible ACS from three US sites (November 2013–January 2016). Dr. Henderson McGinnis

Date: June 18th, 2022 Reference: Crombie et al. Resuscitation with blood products in patients with trauma-related haemorrhagic shock receiving prehospital care (RePHILL): a multicentre, open-label, randomised, controlled, phase 3 trial. The Lancet Haematology 2022 Guest Skeptic: Dr. Casey Parker is a Rural Generalist that includes in his practice emergency medicine, anaesthesia and critical care. He is also now a fully fledged "sonologist". Casey currently splits his time between Broome, a small rural hospital in the remote Kimberley region of Western Australia, and a large tertiary ED in sunny Perth. Case: You are working in the emergency department (ED) and receive a call from the Advanced Care Paramedics who are at the scene of a stabbing. Apparently, two rival gangs (Jets and Sharks) had a rumble. The young man has been stabbed in the abdomen and lost a lot of blood. The patient is tachycardic (120 beats/minute), hypotensive (80/60 mmHg) and looks very pale. They have two large bore intravenous (IV) access and are planning to bring them to your ED as soon as possible. The paramedic asks you, “we have saline, and we also have red-cells and this fancy new lyophilised plasma.  Should we give our shocked patient saline or plasma / red cells en route to the ED?”  What do you advise him?  Background: The use of fluids in trauma resuscitation has been studied in a number of trials in recent years. A lot of observational data has been collected from the battlefields of Iraq and Afghanistan. The Control of Major Bleeding After Trauma (COMBAT) Trial was published in the Lancet in 2018. It was a pragmatic, randomised, single-centre trial done at the Denver looking at the use of plasma in the prehospital setting. This trial did not show a statistical mortality benefit within 28 days of injury. First10EM and REBEL EM both did a review of the COMBAT trial.  The Prehospital Air Medical Plasma (PAMPer) trial was published in NEJM, also in 2018.  The goal of this trial was to determine the efficacy and safety of prehospital administration of thawed plasma in injured patients who are at risk for hemorrhagic shock. This trial did report that prehospital administration of plasma was safe and resulted in lower 30-day mortality. PAMPer was reviewed by First10EM and The Bottom Line.  The traditional teaching in trauma is to replace blood with blood products, so we would expect that we should see a benefit if we used blood and plasma instead of saline alone for the initial resuscitation. Clinical Question: In the resuscitation of pre-hospital trauma patients with hemorrhagic shock is there a patient-oriented benefit to using blood and plasma over 0.9% saline? Reference: Crombie et al. Resuscitation with blood products in patients with trauma-related haemorrhagic shock receiving prehospital care (RePHILL): a multicentre, open-label, randomised, controlled, phase 3 trial. The Lancet Haematology 2022 Population: Adult patients 16 years of age or older suffering traumatic injury resulting in shock believed to be due to a traumatic haemorrhage. Shock was defined as a systolic BP less than 90 mmHg or an absent radial pulse.  Exclusions: Patients known to refuse blood produces, those who received transfusion of prehospital blood products before assessment for eligibility, pregnancy (known or apparent), isolated head injury without evidence of major haemorrhage, and prisoners.  Intervention: Up to four units of blood products boluses one unit at a time.  Units were alternating between units of O-negative packed red cells (PRBC) or or reconstituted lyophilised plasma to a maximum of two units of either. Comparison: Up to four boluses of 0.9% saline (250ml/bolus) Outcome:  Primary Outcome: Composite outcome of mortality from time of injury to hospital discharge or the failure to clear lactate by 20% within the first two hours after randomisation.

Date: June 12th, 2022 Reference: Finfer et al. Balanced Multielectrolyte Solution versus Saline in Critically Ill Adults. NEJM 2022. Guest Skeptic: Dr. Aaron Skolnik is an Assistant Professor of Emergency Medicine at the Mayo Clinic Alix School of Medicine and Consultant in the Department of Critical Care Medicine at Mayo Clinic Arizona.  He is board certified in Emergency Medicine, Medical Toxicology, Addiction Medicine, Internal Medicine-Critical Care, and Neurocritical Care.  Aaron is a full-time multidisciplinary intensivist.  He is the Medical Director of Respiratory Care for Mayo Clinic Arizona and is most proud of his position as medical student clerkship director for critical care. Case: A 62-year-old man is brought in by EMS from home with lethargy and hypotension.  Chest x-ray is clear, labs are remarkable for a leukocytosis of 16,000 with left shift; exam is notable for left flank pain and costovertebral tenderness.  Straight catheter urinalysis is grossly cloudy, and pyuria is present on microscopy.  Blood pressure is 85/50 mmHg.  You wonder which IV fluid should you order? Background:  There has been a longstanding debate about which intravenous fluid is the best for volume resuscitating critically ill patients.  We’ve known for some time that albumin is bad for injured brains, and that hydroxyethyl starch solutions have been associated with kidney injury and mortality.  Since then that debate has broadly centered on the choice between what we will call “abnormal saline” (0.9% sodium chloride), and balanced crystalloid solutions, meaning those with a chloride composition closer to plasma such as lactated ringer’s or Plasma Lyte 148. Early work suggested potential harm from 0.9% saline, that may be partly driven by kidney injury associated with the administration of high-chloride content IV fluids. In the last few years, the pendulum has swung back and forth.  Two large, cluster-randomized trials (SMARTand SALT-ED) showed a small benefit to the use of balanced crystalloids in preventing a composite outcome of Major Adverse Kidney Events within 30 days (aka MAKE-30). Then, the BaSICS trial (a multicentred RCT done in 75 Brazilian ICUs) came along and compared saline to Plasma-Lyte at what the authors deemed slow and fast infusion rates.  We reviewed that last time on SGEM#347. There was no interaction between fluid type or rate of infusion with the primary outcome of 90-day survival.  Among 19 secondary outcomes, which should only be considered hypothesis generating, SOFA scores and neuro SOFA scores at day seven were worse in the balanced crystalloid group. Now we have the PLUS trial, from Australia and New Zealand to add to the medical literature on this issue. Clinical Question: Is the 90-day mortality in critically ill adult patients lower with the use of Plasma-Lyte 148, a balanced crystalloid solution, for fluid resuscitation and therapy, than with the use of normal saline? Reference:  Finfer et al. Balanced Multielectrolyte Solution versus Saline in Critically Ill Adults. NEJM 2022. Population: Patients 18 years or older, admitted to 53 ANZ ICUs over 38 months, whom the treating clinician deemed to need fluid resuscitation and were expected to be in the ICU on three consecutive days. Exclusions: Patients with specific ICU fluid requirements, those who received disqualifying fluid prior to enrollment (> 500 mL in the ICU), those at imminent risk for death or with life expectancy < 90 days, and those at risk for cerebral edema. Intervention: Plasma-Lyte 148 for all resuscitation episodes while in ICU for up to 90 days after the first episode of fluid resuscitation Comparison: 0.9% saline for all resuscitation episodes while in ICU for up to 90 days after the first episode of fluid resuscitation Outcome: Primary Outcome: All-cause mortality within 90 days after randomization Secondary Outcomes: Peak serum creatinine level during the f...

Date: May 24th, 2022 Reference: Broder et al. Guidelines for Reasonable and Appropriate Care in the Emergency Department (GRACE) 2: Low-Risk, Recurrent Abdominal Pain in the Emergency Department. AEM May 2022 Guest Skeptic: Dr. Justin Morgenstern is an emergency physician and the creator of the #FOAMed project called First10EM.com Case: A 33-year-old male presents to the emergency department (ED) complaining of abdominal pain. He states he has had the same pain for more than 10 years, and no one has ever been able to figure out what is going on. He doesn’t have any specific symptoms today, including no fever, vomiting, diarrhea, or urinary symptoms. His vital signs are normal. His abdomen is diffusely tender, but without any surgical findings. You review his chart and note that he has had five CTs performed in the last year at your hospital alone, all of which were negative. You are worried about the cumulative radiation dose he has received but find it hard to exclude significant pathology on history and physical. After all, even patients with chronic abdominal pain can develop a new acute issue like appendicitis. Background: The Society of Academic Emergency Medicine (SAEM) has launched an initiative called GRACE which stands for Guidelines for Reasonable and Appropriate Care in the Emergency Department. GRACE-1 The first GRACE publication looked at low risk chest pain, and in my opinion, they filled a very valuable role. Most guidelines focus on a single emergency visit in isolation, but a patient who presents to the emergency department recurrently with the same symptoms may require a different approach. In the context of recurrent chest pain, they made eight key recommendations. The SGEM bottom line was there is moderate level of evidence that ACS can be excluded in adult patients with recurrent, low-risk chest pain using a single hs-troponin below a validated threshold without further diagnostic testing in patients who have a CCTA within the past two years showing no coronary stenosis. The writing group of GRACE-2 wanted to look at clinically relevant questions to address the care of adult patients with low-risk, recurrent, previously undifferentiated abdominal pain in the ED. Through consensus, four questions were developed and then a systematic review of the literature was performed. This literature was then synthesized to come up with recommendations, following GRADE methodology. GRADE stands for Grading of Recommendations, Assessment, Development, and Evaluation, it was pioneered at McMaster University, in creating rigorous, transparent, and trustworthy guidelines on common clinical problems for EM physicians that are not always directly studied in EM research activities. There can be many presentations for low-risk abdominal pain. We have covered cannabis hyperemesis on SGEM#318 and SGEM#46 and pediatric gastroenteritis on SGEM#254. Clinical Question: What are the recommendations for managing patients with low-risk, recurrent, previously undifferentiated abdominal pain in the ED? Dr. Joshua Broder Reference: Broder et al. Guidelines for Reasonable and Appropriate Care in the Emergency Department (GRACE) 2: Low-Risk, Recurrent Abdominal Pain in the Emergency Department. AEM May 2022 This is an SGEMHOP episode which means we have the lead author on the show. Dr. Joshua Broder is the Residency Program Director and Vice Chief for Education In the Division of Emergency Medicine Duke University School of Medicine. Authors’ Conclusions: “No direct evidence exists to direct the care of patients with low-risk recurrent undifferentiated abdominal pain in the ED. Improved definitions are required to better define this population, and clinically relevant outcomes of interest should be described and studied with rigorous research methodology to inform future clinical guidelines.” Quality Checklist for a Guideline: The study population included or focused on those in the e...

Date: May 13th, 2022 Reference: Abril et al. The Relative Efficacy of Seven Skeletal Muscle Relaxants. An Analysis of Data From Randomized Studies. J Emerg Med 2022 Guest Skeptic: Dr. Sergey Motov is an Emergency Physician in the Department of Emergency Medicine, Maimonides Medical Center in New York City. He is also one of the world’s leading researchers on pain management in the emergency department and specifically the use of ketamine. His twitter handle is @PainFreeED. Case: A 45-year-old man without a significant past medical history presents to your emergency department (ED) with two days of severe lower back pain after shoveling some dirt. The pain is 10/10 in intensity, gets worse with bending, turning, and prolonged walking. He denies numbness or paresthesia in both lower extremities, as well as bowel or bladder dysfunctions. A heating pad and acetaminophen has not helped with the pain. On examination, he is in moderate distress and has prominent tenderness to palpation at the bilateral paralumbar region and intact neurovascular examination. You diagnose him with a lumbar muscle strain and plan to prescribe him a non-steroidal anti-inflammatory (NSAID) while setting expectations. However, the patient wonders if you can give him something that can relax his back muscles and take his pain away. Background: Low back pain (LBP) is one of the most encountered ailments in clinical practice and is responsible for 2.6 million visits to U.S. EDs annually (1). Many patients with acute LBP experience substantial improvement in the first month, but up to one third report persistent back pain, and 1 in 5 report some limitations in activity. These persistent symptoms are associated with high costs, including those related to health care, and indirect costs from missed work or reduced productivity (2). Many pharmaceutical treatments besides opioids have been tried to address acute LBP pain with limited success (SGEM#87 and SGEM#173). These include: acetaminophen (Williams et al Lancet 2014), steroids (Balakrishnamoorthy et al Emerg Med J 2014) and benzodiazepines (Friedman et al Ann Emerg Med 2017). Nonsteroidal anti-inflammatory drugs (NSAIDs) are recommended as first-line medication therapy for patients with LBP despite a lack of evidence of efficacy (Machado et al Ann Rheum Dis 2017), There are several non-pharmaceutical treatments that have also been tried to treat LBP. They include: CBT and mindfulness (Cherkin et al JAMA 2016), chiropractic (Paige et al JAMA 2017), physical therapy (Paolucci et al J Pain Research 2018) and acupuncture (Colquhoun and Novella Anesthesia and Analgesia 2013). Unfortunately, none of these other treatment modalities has high-quality evidence supporting their use. Skeletal muscle relaxants (SMRs) are a frequently used in the ED and at discharge for acute back pain management and include methocarbamol, cyclobenzaprine, orphenadrine, carisoprodol, tizanidine, metaxalone, and baclofen. Estimates suggest up to 35% of patients with nonspecific low back pain are prescribed SMRs, with orphenadrine, and methocarbamol being used in more than 250,000 U.S. ED visits for low back pain annually (3-5). Despite their branding as muscle relaxants, the anti-spasmodic and analgesic effects of SMRs are predominantly due to unknown mechanism of action. Clinical Question: What is the efficacy of skeletal muscle relaxant administration in addition to an NSAID in treating acute low back pain? Reference: Abril et al. The Relative Efficacy of Seven Skeletal Muscle Relaxants. An Analysis of Data From Randomized Studies. J Emerg Med 2022 Population: Patients were considered for inclusion if they were 18– 69 years of age and presented to the ED primarily for management of acute LBP. This was defined as pain of two weeks’ duration or less originating between the lower border of the scapulae and the upper gluteal folds, and received a diagnosis consistent with nontraumatic,

Date: April 19th, 2022 Guest Skeptic: Sarah Mojarad is a Lecturer in Advanced Writing, #SciComm, & Mis/disinfo topics • Kavli Fellow • Reed Awardee. Sarah Mojarad This is an SGEM Xtra episode. When planning a brief trip to Los Angeles for the EMRAP One Conference, I remembered that Sarah is from LA. I thought to myself, perhaps she would come on the SGEM as a special guest. I'm happy to say Sarah graciously accepted the invitation. We recorded the episode sitting outside on the patio at the Luskin Conference Centre. It is an example of how twitter can be a great way for making new friends. When I reached out to Sarah for a topic for the podcast she suggested five tips for science communication (SciComm) using social media. She shared with me a short YouTube video she had made for students interested in SciComm. We based our discussion on that video. It is clearly not an exhaustive list of tips but it did serve as the basis of our discussion. You can hear our conversation on the SGEM Xtra Podcast. Five Tips for Science Communication Tip #1: Be Yourself I think this is such an important piece of advice. Authenticity really resonates with people. One of the best compliments I received recently was from a wonderful dental student named Ellie from Schulich School of Medicine and Dentistry. We met at an Interprofessional Educational event, and she said it was so great to meet someone IRL who is so much like their twitter feed. Follow me and you will find out I am a huge advocate for evidence-based medicine (EBM), love Star Trek TOS, have a dog named Loki the Dog of Mischief, upset other physicians like neurologists when discussing the evidence for tPA in acute ischemic stroke, I think the 80’s is the best era for music/movies, and have been known to play BatDoc at times. Tip #2: Don't’ Be Afraid of Failing Another great tip. One of the best presentations I gave was about my many failures. The joke was that first grade was the longest two years of my life because I needed to repeat grade one. I failed to get into medical school the first time. I felt guilty and inadequate when I could not complete my orthopaedic residency. These and so many other “failures” that cause a lot of pain over the years. However, as Maya Angelou said: “Without defeats, how do you really know who the hell you are? If you never had to stand up to something - to get up, to be knocked down, and to get up again - life can walk over you wearing football cleats. But each time you do get up, you're bigger, taller, finer, more beautiful, more kind, more understanding, more loving. Each time you get up, you're more inclusive. More people can stand under your umbrella.” Tip #3: Find A Mentor I have had many mentors over the years. These include amazing people like: Dr. Kirsty Challen, Dr. Andrew Worster, Dr. Dara Kass, Dr. Michelle Johnson, Dr. Rick Bukata, Dr. Chris Carpenter and many, many more people who have helped me get where I am today. Sir Isaac Newton Tip #4: What Do You Want to Say? What is your message? Do you have a story, a narrative or goal in mind? My goal for the SGEM is to provide structured critical appraisals of the recent literature and probe it for its validity. We are trying to cut the knowledge translation window down from over ten years to less than one year using the power of social media. Ultimately, the goal is for patients to get the best care, based on the best evidence. Tip #5 How Do You Want to Say It? I want to make critical appraisal, clinical epidemiology, and biostatistics fun, engaging and exciting. I try to do this with 80’s music, memes, twitter polls, the keener contest, and other things. I learned a lot from Ross Fisher and his P Cubed Presentation initiative on how to create better presentations. I really like the way Melanie Trecek-King from Thinking is Power does her SciComm. She has a great educational approach and posts some useful tools f...

Date: April 16th, 2022 Reference: Blom et al. Common elective orthopaedic procedures and their clinical effectiveness: umbrella review of level 1 evidence. BMJ 2021 Guest Skeptic: Dr. Matt Schmitz, Pediatric Orthopedics, Adolescent Sports Medicine and Young Adult Hip Preservation Surgeon at San Antonio Military Medical Center in Texas. Disclaimer: The views and opinions of this blog and podcast do not represent the United States Government or the US Military. Case: A 55-year-old man comes into the emergency department (ED) for increasing knee pain and decrease in function. He’s had an anterior cruciate ligament (ACL) repair and used to run marathons. However, he is finding it more difficult to even put his socks on. Physical exam shows varus deformity at the knee, decreased range of motion, crepitus, no locking and neurovascularly intact distal. X-rays show severe, tri-compartment arthritis. Background: Musculoskeletal complaints are one of the most common presentations to emergency departments. Often emergency physicians are assessing, treating, and answering patients question about orthopedic surgical procedures. How good is the evidence for the most common elective procedures? Before we answer that question, let’s remind everyone that only a small number (2.8%) of interventions published in SRMA and relevant to emergency medicine have unbiased and strong evidence for improved outcomes (SGEM#361). This is a broader problem in medicine. Tricoci et al. JAMA Feb 2009 looked at the ACC/AHA guidelines from 1984 to 2008. They found 53 guidelines with 7,196 recommendations. Only 11% of recommendations were considered Level A, 39% were Level B and 50% were Level C. An update was published by Fanaroff et al in JAMA 2019. The level of high-quality evidence had not changed much when looking at the ACC/AHA guidelines from 2008-2018. There were 26 guidelines with 2,930 recommendations. Now Level A recommendations were down to 9%, Level B 50% and Level C 41%. Time to turn our skeptical eye to the evidence for elective orthopaedic procedures. Clinical Question: What is the effectiveness of common elective orthopaedic procedures compared with no treatment, placebo, or non-operative care? Reference: Blom et al. Common elective orthopaedic procedures and their clinical effectiveness: umbrella review of level 1 evidence. BMJ 2021 Population: Meta-analyses of randomised controlled trials Exclusions: Network meta-analyses (when pairwise meta-analyses were available), narrative reviews, systematic reviews that did not pool data or do a meta-analysis, and meeting abstracts Intervention: Surgery Comparison: No treatment, placebo, or non-operative care Outcome: Quality and quantity of evidence behind the ten most common elective orthopaedic surgeries and comparisons with the strength of recommendations in relevant national clinical guidelines. Authors’ Conclusions: “Although they may be effective overall or in certain subgroups, no strong, high quality evidence base shows that many commonly performed elective orthopaedic procedures are more effective than non-operative alternatives. Despite the lack of strong evidence, some of these procedures are still recommended by national guidelines in certain situations.” Quality Checklist for Therapeutic Systematic Reviews: The clinical question is sensible and answerable.  Yes/Unsure The search for studies was detailed and exhaustive. Yes The primary studies were of high methodological quality. Yes The assessment of studies were reproducible. Yes The outcomes were clinically relevant. Yes There was low statistical heterogeneity for the primary outcomes. Unsure The treatment effect was large enough and precise enough to be clinically significant. Yes, No and Unsure Results: The ten most common elective orthopaedic procedures were identified using a literature search,

Date: April 7th, 2022 Reference: Wong et al. Sensitivity of diffusion-weighted magnetic resonance imaging in transient global amnesia as a function of time from symptom onset. AEM April 2022 Guest Skeptic: Dr. Chris Bond is an emergency medicine physician and assistant Professor at the University of Calgary. Case: A 65-year-old man presents to your emergency department with his wife. She tells you that he woke up normally this morning, but after breakfast he began asking the same questions repetitively and was amnestic to the answer, seemingly unable to form new memories. He remained completely awake and alert and otherwise appeared well.  There was no history of recent trauma, infectious symptoms, or any other illness.  Background: Transient global amnesia (TGA) is an idiopathic acute neurological disorder that presents with sudden onset anterograde memory loss. It was first described as a syndrome in 1956 by Courjon and Guyotat and also by Bender [1,2].  Fisher and Adams formally described as TGA in 1964 [3]. The usual presentation is a patient between 50 and 70 years of age who are cognitively and neurologically intact but asking repetitive questions, unable to form new memory. Symptoms do not last very long and resolve within 24 hours. The incidence has been reported as 23.5 per 100,000 people per year [4] and is more common in people who get migraine headaches [5]. TGA is often precipitated by physical or emotional stressors, pain, the Valsalva maneuver, hot or cold-water immersion or sexual intercourse [6] Diagnosing TGA combines items put forward by Hodges and Warlow and Caplan [7-9]. This results in seven diagnostic criteria for TGA. Diagnostic Criteria for Transient Global Amnesia Attack is witnessed Clear-cut anterograde amnesia during the attack No neurologic symptoms or signs during the attack other than amnesia (no clouding of consciousness or loss of personal identity) No neurologic physical examination findings others than anterograde amnesia Memory loss is transient (resolution within 24 h) No epileptic features and no active epilepsy (defined as no seizure within 2 years or on antiepileptic medication) No recent head injury A diagnostic algorithm has been published for patients with sudden onset of anterograde amnesia [6]. Included in this differential is transient epileptic amnesia, transient ischemic attack, stroke, metabolic disorders, psychogenic disorders, and post traumatic amnesia. The workup can include laboratory testing, EEGs, ECGs, echocardiogram and advanced neuroimaging. Clinical Question: What is the sensitivity of diffusion-weighted magnetic resonance imaging (DW-MRI) as a function of time from symptom onset compared to clinical diagnosis of TGA? Reference: Wong et al. Sensitivity of diffusion-weighted magnetic resonance imaging in transient global amnesia as a function of time from symptom onset. AEM April 2022 Population: Adult patients 16 years of age and older with a diagnosis of TGA based on the existing clinical criteria Intervention: Evaluation with DW-MRI at varying time intervals post symptom onset Comparison: No comparison as no studies of patients without DW-MRI were included Outcome: Sensitivity of DW-MRI in diagnosis of TGA Dr. Matt Wong This is a back-to-back SGEMHOP episode. We did the March episode at the end of last month and the April episode is the first week of this month. We are pleased to have the lead author on the show. Dr. Matthew Wong is an emergency physician and educator at Beth Israel Deaconess Medical Center, and an Assistant Professor at Harvard Medical School. Authors’ Conclusions: “DW-MRI lesions are uncommon in patients with TGA early after symptom onset, but the sensitivity (i.e., positivity rate) of DW-MRI increases with time. Despite the limited quality of existing evidence, obtaining an early DW-MRI in patients with clinical diagnosis of TGA in the acu...