RCT of ED Renal Ultrasound for renal colic

The Trial

Smith-Bindman R, Aubin C, Bailitz J, Bengiamin RN, Camargo CA Jr., Corbo J, et al. Ultrasonography versus Computed Tomography for Suspected Nephrolithiasis. N Engl J Med. 2014 Sep 18;371(12):1100–10. 

They managed to come up with the STONE trial as acronym for this one. [Study of Tomography Of Nephrolithiasis Evaluation]

This is big news for USS, as it’s an RCT of the use of ED US use. Ultrasound, of course, makes sense to lots of us who see the probe as some sort of prehensile extension of the human body able to go forth and grasp the diagnosis. Still it’s nice to have some data to help us better understand how it helps our practice.

Here’s the details as I read them.

METHODS

  • multi centre randomised trial. All good so far
  • Randomisation could have been better described I thought
  • 3 Groups
    • ED performed US by an EP credentialed in US – unclear if these were US super users or just regular punters with basic level US skills
    • Radiology perfromed US
    • CT
  • The first major concern is in the lack of blinding. Though it’s hard to see how you could blind this.
  • the ultimate decisions on imaging and disposal after the randomised imaging were down to the EP looking after the pt. So people afer US could go on to have CT if this was felt to be needed
  • Unclear if the EP looking after the doc was also looking after the patient
  • 3 Primary outcomes (which is a tad naughty. The prmary outcome should of course be, primary I would have thought)
    • “high-risk diagnoses with complications that could be re- lated to missed or delayed diagnoses”. The obvious one here might be a missed AAA for example. the missed pathology was pre defined and categorised by a number of the authors all independent of each other.
    • cumulative radiation exposure (does imaging beget imaging)
    • total costs (which I presume is for a different paper, as it’s not reported here)
  • follow up was by repeated phone calls and a structured interview
  • diagnostic accuracy was a secondary outcome but the gold standard here was the patient reporting stone passage or surgical removal. This is important as most people consider CT as the gold standard but as this is one of the modalities being assessed it would be “incorporation bias”  to include CT in the gold standard

RESULTS

  • screened 3700, took 2700
  • 3-5% lost to follow up which may be a problem – is the reason they didn’t answer the phone at follow up due to the fact they were dead? The reassuring thing is that lost to follow up was similar between groups
  • 40% in this trial had a prior history of stone
  • most were youngish and the most of the time the doc had a >50% pre-test probability of stone. Which is common – stones are usually obvious and most CTs we do for stone are positive, at least in my experience anyhow
  • only 8% were admitted from the ED. This is amazing to me as we admit almost all our query stones. Either because we can’t get a CT at 3am for a stone (let’s face it the priority is pain control not diagnosis here) or because we need to get them a urologist (who only have a weekday service in our place). Our admissions are short but still, it’s nice to see that it is more than possible to manage these as out patients in a less dysfunctional system than ours in Ireland.
  • Primary outcomes
    • the missed high risk diagnoses were tiny (you have to look in the supplementary appendix for this
      • ED US – 6. One bowel obstruction but mainly people returning with infections
      • Rad US – 3  – one missed ovarian torsion and the others infective
      • CT – 2 – infective complicatons
      • All of these were less than 1% and of course when the numbers are this tiny, there’s no statistical difference between them. Worth noting that the infective complications are going to be there no matter what you do, no imaging is going to be definitive for pyelo most of the time.
  • There was significantly less radiation in both US groups. Which is hardly surprising. The excess radiaiton in the CT group was all due to the index CT and not lots of follow up CTs thankfully.
  • One of the most interesting things to me was the accuracy of all 3 tests. Remember that the gold standard here was stone passage of surgery. All 3 tests had identical sens/spec. Sensitivity of 85% and spec of 50%.
  • 40% of those in the ED US group went on to have a CT anyhow at the docs discretion. 27% of the rad group went on to have CT. Again, this is hardly surprising. People simply don’t trust US and most urologists want a CT, I know ours do. Despite the fact that even their guidelines suggest US as the investigation of choice if available.

THOUGHTS

  • This is a great effort and a substantial trial. As we probably already knew, EP performed US appears safe and accurate when we pose a focused question. There will always be misses but the numbers here are tiny and are more clinical judgement related than imaging related.
  • The issue will be dealing with the specialists who may not be able, or willing to deal with just the US. I don’t say that to be critical, there may be lots of good reasons to pursue further imaging, but there doesn’t seem to be much need for the young, uncomplicated, clinically typical stone.

Finally, the entire study protocol is available as a PDF of supplementary material on the NEJM site and is a fascinating insight into the background of putting together an RCT and the sheer volume of work required for it.

Want more renal ultrasound:

The LINC trial

I wouldn’t regard myself as a total nihilist when it comes to cardiac arrest but I’m usually not on the optimistic side. I work in a typical inner city setting where outcomes from OOHCA are on the poor side. I suspect are numbers are polluted by the fact that our local EMS system only occasionally stops CPR on scene. We get a lot of patients transported with (manual) CPR in progress. Most of these patients have not responded to a substantial period of ACLS and are simply dead and typically I stop resus as soon as they arrive.

There are of course some very important exceptions to this, the people who we know have a more favourable outcomes: bystander CPR, short down times, reversible causes, VF/VT, younger age etc… These are the people where the mantra of maximally aggressive care goes into action. Thus there’s a stark contrast in my practice between the patients who appear to me to be obviously dead and don’t need ACLS – they need a death certificate – and the patients for whom ACLS is simply not enough, or at the very least it doesn’t account for the nuances needed in advanced critical care.

The FOAMed sphere is full of advanced resuscitation resources from some of the best resuscitationists in the world. That’s where I’ve learned most of my critical care.

All this is just an introduction to the LINC trial. It’s been out for a while and I’ve linked to some of the other FOAMed reviews out there but I figured I’d throw in my own two cent.

METHODS

  • industry sponsored RCT
  • Sweden, Netherlands and UK
  • excluded those with an inappropriate body size so we don’t know how many this will be applicable to
  • the LUCAS protocol had a slightly different protocol with 3 mins v 2 mins. It has been suggested that was due to rescuer fatigue in the manual group. But either way it shows that the two groups were not treated the same. The mechanical group also got an extra DCC 90 secs after the LUCAS was put on.
  • outcome was survival at 4 hrs which is a bit soft
  • CPC outcome was done from the notes which is open to some biases
  • those with ROSC got hypothermia for all rhythms though I don’t think this was pre hospital
  • they assumed a 25% 4 hr survival which seems a touch high but then they weren’t measuring good neuro survival here as a primary outcomes

RESULTS

  • 2500 pts 30% VF/VT
  • 23% survival for both groups
  • in those that survived there was about a 35% PCI rate.
  • 8% surviving to hospital discharge with good outcome (CPC 1&2)
  • it is interesting to note that you either died or you did well. There weren’t many survivors with bad outcomes. Which is perhaps the most important finding of the whole study. They were virtually all CPC 1. It may be that when a poor outcome was anticipated (say at day 3 post arrest) then aggressive treatment was withdrawn and the patient succumbed.

THOUGHTS

This is a remarkably negative study from a strictly EBM point of view. So any routine (ie for every single cardiac arrest) use is hard to justify given the cost of implementing this device in all EDs and all EMS crews.

Good, coordinated, team CPR is hard to do well and like most things you only get really good at it when you practice. A lot. Like most EDs I’ve worked in we don’t practice, we do our ACLS courses but we don’t practice as a group to deal with all the small logistic factors that turn a straightforward resus into a chicken bomb. We use the LUCAS in certain cases  – the exceptions where I think continuing CPR will allow an intervention or produce a positive outcome – an every time I do I’ve noticed a better atmosphere in the room. As the team leader (as well as the interventionalist – it’s usually just me and my nurses and some very junior docs who can’t even put an IO in) it allows me a bit more cognitive space as I don’t need to keep an eye to monitor the rate and quality of the CPR.

If ECLS becomes a mainstream possibility (which in this country seems unlikely) then mechanical CPR is likely to have even more of a role. The key is of course patient selection. The heart too good to die is fairly rare. For most patients I look after, cardiac arrest is the natural course of age and massive comorbidity.

The logistic factors that give you an advantage (freeing up hands and cognitive space) for those long and infrequent resus cases that makes me glad that we still have one in the resus room.

References:

Hallstrom Al, Rea TD, Sayre MR, Christenson J, Anton AR, Mosesso VN, et al. Manual Chest Compression vs Use of an Automated Chest Compression Device During Resuscitation Following Out-of-Hospital Cardiac Arrest: A Randomized Trial. JAMA. American Medical Association; 2006 Jun 14;295(22):2620–8.

Rubertsson S, Lindgren E, Smekal D, Östlund O, Silfverstolpe J, Lichtveld RA, et al. Mechanical Chest Compressions and Simultaneous Defibrillation vs Conventional Cardiopulmonary Resuscitation in Out-of-Hospital Cardiac Arrest. JAMA. 2013 Nov 17.

FOAMed Reviews:

Rory Spiegel at EMLit of Note

ALIEM

LITFL CCC

ScanCrit

Image Credit Wikimedia Commons

Outcomes in Subsegmental PE

This is a big and important topic but still a little bit confusing to say the least.

The way I want to view the world is like this.

PE is not a single disease but instead something we should call by different names.

1) Pulmonary Fluff or Lung Lint

– these are the tiny sub segmental PEs that we diagnose because diagnostic protocols bend our arms and force us to become bad doctors and it’s not our fault… These PEs get 3 or 6 months anticoagulation and we cross our fingers and hope they don’t die from the anticoagulation.

2) The thrombus of death

– these are the sickish looking people whom you are actually worries about and have high clot burdens and strainy looking hearts and ECGs. These PEs are the ones you think about giving the drug of the big pharma devil to – tPA.

In my imaginary rose tinted world, fluff gets no treatment and the thrombus of death gets tPA.

The problem is that the reality is a whole lot more complicated than that. There is good reason that we treat the small PEs just like the bigger ones. We simply don’t know if they’re dangerous or not so we err on the side of “if in doubt treat” (despite the fact that the evidence for anti-coagulating any PEs is a little ropey)

This paper suggests that these small PEs might be more dangerous than I’d like to believe. [Hat tip to EMU for making me aware of this]

Exter den PL, van Es J, Klok FA, Kroft LJ, Kruip MJHA, Kamphuisen PW, et al. Risk profile and clinical outcome of symptomatic subsegmental acute pulmonary embolism. Blood. 2013 Aug 15;122(7):1144–9. [Full Text Link]

METHODS

  • data from 2 prior observational diagnostic studies, one was the Christopher study, the other was much smaller. Both European
  • as a result the data is only as good as the original studies which in this case should have been pretty good
  • death where PE could not be ruled out as a cause were considered recurrent PE. Not great but probably the best way to do it.
  • logistic regression used to see if there was an association between where the PE was and the outcomes

RESULTS

  • 3800 pts, 2700 of which got CTPA
  • 21% had PE overall.
  • 115 people with isolated Sub Segmental PE (SSPE)
  • they appeared similar to those with more proximal PEs (except for Wells scores, where they tended to be lower)
  • 3 month follow up was better than 99%
  • 4/115 developed VTE in 3 month follow up. the numbers come out at 3.6% v 2.5% suggesting recurrent VTE more likely in the small PEs!
  • of note those in whom PE was ruled out developed VTE 0.8% of the time

THOUGHTS

  • I’d love to know the details of the 4 people who developed recurrent VTE in the SSPE group but they don’t tell us
  • the mortality numbers are quite high 10% for SSPE, 6.3% for more proximal PE and 5% for those in whom it was ruled out. This seems very high. 1 in 20 who had a negative work up for PE were dead in 3 months?
  • this seems like a very sick population where 1 in 20 of those with a -ve PE work up were dead in 3 months
  • the numbers with SSPE here are very small (115)compared to the overall numbers and therefore the number of people for whom the outcome of interest occurred (recurrent VTE or death) was absolutely tiny.
  • Everyone in this study was treated which we are assuming is an effective treatment. Therefore this study tells us the natural history of treated SSPEs. It would be really nice to know what the natural history of untreated SSPEs is.

Ryan over at EMLitofnote has reviewed the paper too.

UPDATE 17-5-14

Mattia Quarta of EMPills fame has this to say:

Dear Andy thanks for sharing your thoughts on this paper.

One thing I’ve noticed is that the prevalence of SSPE between the two cohorts that were merged for this study seems pretty different. In the Christopher study 110 SSPE were found which means that only 6 come from Klok publication.
So it’s more less 17% vs 5%. Apparently the two cohorts are not so homogenous after all.
In the Christopher study as opposed to Klok PE level determination apparently was not specifically planned. All 41 PEs excluded because localization was not reported belong to the Christopher study.
Klok and colleagues adopted a specific strategy to locate the level of the clots found. So I wonder whether Cristhopher data are completely reliable when it comes to PE level, considering that a certain grade of variability exists between radiologists in the interpretation of subsegmental clots. With these numbers even one patient can make a huge difference in the results.

I’m not really sure this study will change my point of view on SSPE. For the moment I still lean toward the same imaginary rose tinted idea that fluff gets no treatment unless they have DVT.

I’ll wait until we have more data. http://clinicaltrials.gov/show/NCT01455818

Time to treatment for stroke and problems with observational data

Here’s a big study suggesting earlier TPA treatment for stroke results in better outcomes. This of course isn’t a new idea but this is new data here to support it:

Saver JL, Fonarow GC, Smith EE, Reeves MJ. Time to treatment with intravenous tissue plasminogen activator and outcome from acute ischemic stroke. JAMA. 2013. PMID 23780461

METHODS

  • data from the get with the guidelines registry (ran by American Heart and American Stroke Associations)
  • web based data collection tool for providers to enter patients into
  • from 2003-2012 which should quite the spectrum to include pre ECASS III and post ECASS III data
  • patients got into this either prospectively as they got treated or retrospectively by someone identifying a stroke on discharge documentation and entering them into the regsitry . The retrospective data is what we should be particularly suspicious of – you could easily pick and choose the ones you want to enter into the registry. Ultimately this is a study of patients that someone decided to enter into a registry. Some patients with data relevant to this question may well not be entered and therefore we don’t know what happened to them.
  • excluded patients (for this analysis): poor documentation, sites that had few stroke pts in the registry and those who got intra arterial treatments
  • there are, as usual, a lot of conflicts of interest and indeed the registry itself is funded by a pharmaceutical company (and has been funded by several others in the past)

RESULTS

  • 2000 hospitals submitting 1.2 million patients. So there’s a lot of data in this registry
  • they report 6% of these getting TPA
  • they further examine this 6% but exclude all the ones with dubious times, all the ones post 4.5 hrs and all those discharged to other hospitals (for whom they say they couldn’t get good outcome data). There are various other exclusions along the way.
  • note they don’t use the standard stroke outcomes of modified Rankin scale here. They use “ambulatory at discharge” or “discharge home” as surrogates of good outcome. This is even more dubious than the usual mRS assessed by postal questionnaire.
  • ultimately after all the slicing and dicing we get 58300 pts.
  • median time at treatment was 144 mins. 10% treated before 90 mins
  • they report 8.8% mortality, 4.9% ICH, 33% walking at discharge and 38% discharged home. Remember all the exclusions that went into this before hand so these numbers may be on the slightly optimistic side.
  • by comparing all these they find +ve associations between time to treatment and all of the outcomes. Because of the massive numbers all of these are statistically significant.
  • they even calculate NNTs to compare how much better people do when they are treated quickly.

THOUGHTS

  • The basic demographic data and the number generated have important audit, governance and even actuarial importance.
  • Registry data that is only as good as what people put into it, and it’s not clear how good that data is.
  • From the colossal numbers involved any difference will be statistically significant. Numerically significant and clinically significant are hardly the same.
  • The silliness comes with the comparisons and the implication of causation.
  • The study has no way to account for the confounding factors invovled in why someone might present to the hospital earlier than someone else, or why they might get treated earlier than someone else.
  • For example, it may well be that those who presented earlier were more likely to be having a TIA rather than an established stroke and it may be natural autoregulation and fibrinolysis that resolved their stroke rather than the TIA. Indeed if there was no actual infarcted brain then it is hardly a surprise that rates of ICH were lower in the TIA…ahem… I mean earlier treated group.
  • The point is that this data cannot answer the question they have asked of it. The only data that can answer this question is the data from the RCTs – the very data that is so contentious and controversial (among emergency physicians at least).
  • The associations presented here are all very interesting but add little real science. Rather it reinforces the rhetoric that makes acute stroke the interesting, frantic and emergent condition that we see every day.

The study did, however, remind of two of my favourite bits on causation. The first from XKCD that gets rolled out every month or so on this blog:

correlation

And the most thoughtful and sensible of science writers, the late, great Stephen Jay Gould. This is from an essay critiquing the slightly naive narrative we’ve told of Galileo and his achievements in proving heliocentrism. He interestingly got a little bit carried away and claimed that Saturn didn’t have rings but had two tiny planets at either end. His supportive proof was that he had “observed” it and therefore it must be true. All a touch embarrassing really…

Utterly unbiased observation must rank as a primary myth and shibboleth of science, for we can only see what fits into our mental space, and all description includes interpretation as well as sensory reporting. Moreover, our mental spaces house a complex architecture built of social constraint, historical circumstance, and psychological hope.

P50 The lying stones of Marrakech

Stephen Jay Gould

Further Reading/Listening:

LITFL – CCC Stroke Thrombolysis

LITFL - Michelle Johnston on tPA for stroke

TheNNT.com

EMCrit Cage Match – Jagoda v Swaminathan

The SGEM

Busting the Clotbusters – Domhnall Brannigan

SMART EM – thrombolytics for stroke

 

Age Adjusted D-dimer Cut Offs

This paper recently published trying to confirm if it’s OK to raise the d-dimer cut off in older people.

“Age-Adjusted D-Dimer Cutoff Levels to Rule Out Pulmonary Embolism: the ADJUST-PE Study.” 311, no. 11 (March 19, 2014): 1117–1124. doi:10.1001/jama.2014.2135. PMID 24643601

Hopefully you’ve heard about this already through ER Cast and over on BoringEM (if you want more discussion on d-dimer, then be sure and check out the LITFL page on it.) Basically if you’re over 50 then your new d-dimer cut off is 10 times your age. These guys tested that approach.

METHODS

  • prospective data on pts with suspected PE from Europe.
  • Stratified to low or high risk
  • D-dimers were sent on the low risk ones and if -ve work up was finished. If +ve they went for CTPA
  • follow up at 3 months by phone
  • 3 blinded ‘experts’ adjudicated if something bad happened to them

RESULTS

  • 3300
    • 2900 were ‘non-high’ probability and went down the d-dimer path
    • 400 were high and went straight to scan
  • 330 fell into the ‘age adjusted’ level and all of these guys (who previously would have got advanced imaging) seemed to do well (for what that’s worth)
  • of note their overall rule in rate for PE was 20%, much higher than many contemporary studies

THOUGHTS

We all want ways to rule out PE and avoid the CT scans. This might be another way to safely rule patients out, though it’s worth bearing in mind that it’s only going to affect a small number of patients.

This is by no means a perfect study. The group of interest did not actually get the reference diagnostic test (the CTPA) so we’re dependent on the veracity of their follow up to know if it’s truly OK to pursue this new strategy of age-adjusted cut off and forgo more advanced testing. This is a common problem in studies like this (see the Perry CT for SAH article as a great example of controversy over this very issue) and it doesn’t mean that it’s all nonsense but as always be sure to use your noodle when thinking about it.

Update:
Salim over at REBEL EM has a great post on this summarising the evidence for age adjusted d dimers. There’s actually a lot more evidence than I thought on this.

[Image Credit: Wikimedia Commons]