Faculty: I Rampil, U Landman
This year's journal Club starts with a new three year syllabus. In the first year, we will explore different types of articles and how to evaluate them. In the second year we will read some of Anesthesia's Golden Oldies for perspective, and finally in the third year, we will turn to current literature. Hopefully, the cycle will continue!
As an exercise to put us all the mood to be constructive critics of the medical literature, we will start with an exercise. Attached, there are several blinded abstracts which were submitted for judging for presentation at this years major Anesthesia meeting this October in San Francisco. As one of the official judges, I have selected just a few of the 300 I judged as examples of the best, the worst, and the average.
Drs. Rampil, Bell
"Dark Green Blood in the Operating Theatre" Lancet 2007: 369:1972
"Stiff Person Syndrome and Anesthesia." Anesth Analg 2003; 97:486-7
Drs. Rampil, Moller
Observational Studies and Descriptive Statistics
We all now know a little more regarding parametric tests ANOVA and the nonparametric tests with the interesting names: Chi Square Test, Mann-Whitney Wilcoxon, and Kuskal-Wallis. The continuing discussion about the statistics will help us all understand the statistics that we read about in articles. We now have the insight to see that statistical signicance may not equal clinincal signicance.
Please read the article from Dr. Rampil titled "Statistical Errors in Medical Research - A Review of Common Pitfalls."
Drs. Rampil, Bell
Correlation and Regression
Drs. Rampil and Seidman
Deciding on the applicability of clinical trials to your patients
A paper on how to decide the applicability of clinical trials to your patients.
One of the few double blind randomized trials in anesthesia.
Read the former paper first, then think on its considerations whilst poring over the latter.
Meal ticket (questions about RCT and My Patient)
We now have a guideline relating applicability of studies that we read to our daily patients. As Dr. Rampil said- remember to think of the 6 issues: (2 biologic, 2 social and economic and 2 epidemiologic).
Risk in the Literature
Levine M , Walter S , Lee H , Haines T , Holbrook A , Moyer V .Users' guides to the medical literature. IV. How to use an article about harm. Evidence-Based Medicine Working Group. JAMA. 1994 May 25;271(20):1615-9. <html>
Mangano, D, et al. The Risk Associated with Aprotinin in Cardiac Surgery. NEJM, January 26, 2006, 354; 4: 353-365.
We learned some more new terms: one is propensity analysis and how it related to the article. For more info on this, read
Blackstone EH. Monitoring surgical performance. J Thorac Cardiovasc Surg. 2004 Dec;128(6):807
Dr. Rampil also stated how that evidence is lacking in evidence based medicine for much that we do since "good evidence is expensive."
Best recent article in Anesthesiology
Many in the group had chosen the following article:
Arkoosh, v, et al. A Randomized, Double-masked, Multicenter Comparison of the safety of continuous intrathecal labor analgesia using a 28 gauge catheter versus continuous epidural labor analgesia. Anesthesiology Feb 2008, 286-98.
Many had chosen it because it had clinical relevance or related to a specialty area of interest. It also involved something topical or controversial. Some items to consider that Dr. Rampil summarized:
If you have time, read everythingSo, keep this all in mind when we have limited time and are looking to read some pertinent papers in our spare time.
For a shortcut, read only direct clinical trialsRelevance of area importance in choosing an article
New science and technology will eventually reach a direct clinical trial if it holds up
Is it an interesting and relevant hypothesis?Was the method the best way to answer the question?
Is there controversy?
Is it a new solution to an old problem?
Is it a new idea?
What type of study was it(ie-double blind randomized control, cohort, etc)Was it powered to answer the question?
Describe limits which help you think about applicability
Does results fit into existing knowledge?
Drs. Rampil & Pikus
Avidan, M et al.
Anesthesia Awareness and the Bispectral Index.
New Engl J Med 358; 11, march 13, 2008, 1097-1108.
We were in agreement regarding the statistics used.
They had underpowered the study since patients were recruited under false assumptions. It was not powered well to answer their hypothesis.
Two controversial, yet potentially practice changing articles to review.
This is exactly what residents will face after graduation.
Levine S, Nguyen T, Taylor N, Friscia ME, Budak MT, Rothenberg P, Zhu J, Sachdeva R, Sonnad S, Kaiser LR, Rubinstein NA, Powers SK, Shrager JB.
Rapid disuse atrophy of diaphragm fibers in mechanically ventilated humans.
N Engl J Med. 2008 Mar 27;358(13):1327-35.
Karkouti K, Wijeysundera DN, Yau TM, McCluskey SA, van Rensburg A, Beattie WS.
The influence of baseline hemoglobin concentration on tolerance of anemia in cardiac surgery.
Transfusion. 2008 Apr;48(4):666-72