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A Simple Study May Herald a Big Change in Evidence-Based Medicine

Sensible Medicine

For instance, in the FOURIER trial, the super-expensive PCSCK9 inhibitor, evolocumab, reduced a primary composite outcome (CV death, MI, Stroke, unstable angina, coronary revascularization) vs placebo. We call this acute ischemic stroke or AIS. The absolute risk decrease was just 1.5%, and it was driven by non-fatal outcomes.

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Part 2 - The ELAN Trial Forces Doctors to Be Mature About Using Medical Evidence

Sensible Medicine

Early vs late initiation of oral anticoagulation after an ischemic stroke due to atrial fibrillation. The primary outcome was a composite of lots of bad things—stroke, systemic embolism, intracranial bleeding, extracranial bleeding, and death due to cardiovascular causes. They have randomized 2000 patients to two strategies.

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Grand Rounds Recap 11.29.23

Taming the SRU

Lumbar puncture with xanthochromia or > 2000 RBCs in tube 4 should increase suspicion for SAH. Posterior circulation stroke Patients with posterior strokes will likely have a low NIH. Involve the stroke team if posterior circulation stroke is suspected, as they may be a candidate for TNK, or more rarely, EVT.

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Small Trials vs Large Trials

Sensible Medicine

ISIS-4, with it’s nearly 60,000 patients and more than 2000 events in each treatment group, definitively shows that IV-Mg had no effect on mortality. Now, we randomize fewer patients but record composite outcomes, which may include things like, death and MI and stroke and coronary revascularization. LIMIT-2 publishes in 1992.

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REBEL Cast Ep116: The CLOVERS Trial – Restrictive vs Liberal Fluids in Sepsis-Induced Hypotension

RebelEM

These patients can have a vasodilated vascular bed and the initial use of fluids is hypothesized to serve two purposes: Augmenting the macrovascular system (stroke volume and cardiac output) and augmenting the microvascular perfusion (capillary blood flow). Liberal: 14.9% Estimated Difference: -0.9%; 95% CI 04.4 Read more

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emDOCs Podcast – Episode 100: Acute Chest Syndrome Part 1

EMDocs

National Acute Chest Syndrome Study Group [published correction appears in N Engl J Med 2000 Sep 14;343(11):824]. Infectious: bacterial or viral pneumonia ( M. pneumoniae, C. Based on light absorption from blood flow at the sensor site (using HbA, not HbS) Underestimates alveolar hypoxemia. Vichinsky EP, Neumayr LD, Earles AN, et al.

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emDOCs Podcast – Episode 101: Acute Chest Syndrome Part 2

EMDocs

National Acute Chest Syndrome Study Group [published correction appears in N Engl J Med 2000 Sep 14;343(11):824]. Infectious: bacterial or viral pneumonia ( M. pneumoniae, C. Based on light absorption from blood flow at the sensor site (using HbA, not HbS). Underestimates alveolar hypoxemia. Vichinsky EP, Neumayr LD, Earles AN, et al.