The Skeptics Guide to Emergency Medicine

Date: October 7th, 2021 This is an SGEM Xtra episode. I had the honour of co-presenting at the Renaissance School of Medicine, Stony Brook University, Department of Emergency Medicine Grand Rounds. The title of the talk "From EBM to FBM - Gender Equity in the House of Medicine. You may be wondering: why is a middle aged, white, heterosexual, cis gender, male, atheist, nerd co-presenting on gender equity in the house of medicine? "And isn’t it ironic, don't you think? A little too ironic. And, yeah, I really do think".  According to Sir Patrick Steward (Captain Jean-Luc Picard from Star Trek), “People won’t listen to you or take you seriously unless you’re an old white man, and since I’m an old white man I’m going to use that to help the people who need it” My co-presenter was Dr. Suchismita Datta. She is an Assistant Professor in the Department of Emergency Medicine and GME Diversity Leader for the NYU Long Island School of Medicine. The presentation is available to listen to on iTunes and GooglePlay and all the slides can be downloaded using this LINK. Three Objectives Recognize gender inequity in medicine Identify gender inequities in each of the three pillars of of evidence-based medicine (EBM) Understand how gender inequities can impact the cardiovascular care of women Dr. Datta's Journey Dr. Datta Dr. Datta shares her personal journey from medical school to attending physician and discusses the challenges she faced along the way. She and her husband Neil met at medical school. They both matched to the same emergency medicine (EM) program. After graduation they began working at a high-volume, high-acuity critical access hospital.  After a few years they moved back to New York. Dr. Datta describes her unpaid and paid maternity leave, difficulties in pumping breast milk while on shift and the pay gap she experienced. Gender Inequities Using the EBM Model There are three pillars of EBM. The literature should inform care, guide care but it should not dictate care.  Clinicians must also use their good clinical judgment in applying the literature. We also need to ask patients about what they value and prefer. This can be summarized into a Venn diagram capturing the Dr. Sackett's definition of EBM. The Medical Literature: Who gets most of the grant money in medicine? Men Who rises to the top academic positions at universities? Men Who rises to the top academic positions in medicine? Men Who rises to the top academic positions in Emergency Medicine? Men Who is most likely to be the first author on a medical publication? Men Who is most likely the first author on a emergency medicine publication? Men Who is most likely to be the first author on a Pediatric Emergency Medicine (PEM) Paper? Men Who are often excluded from being subjects in medical research? Women The Clinicians: Who historically has been the clinician in the room? Men Who is most likely to rises to top leadership positions within the hospital structure? Men Who gets paid more in medicine? Men Who gets paid more in academic medicine? Men Who gets paid more in academic Emergency medicine? Men Who is more likely to be introduced with their professional title at grand rounds? Men Who get's paid more in Ontario, Canada? Men What can be done about the gender pay gap? CMAJ 2020 The Patients: Who traditionally was more likely to access health care? Women Who is typically responsible for most family health care needs? Women Who has been systemically under-treated when it comes to painful conditions? Women Who are provided less care for life threatening illnesses like STEMIs? Women   Cardiovascular Disease in Women Gender biases and inequities can seriously impact our clinical management. Cardiovascular disease in women is understudied, women are underrepresented in clinical trials, CVD is under recognized in women, they are being under diagnosed and under treated. This is associated with women having worse outcomes compared to men for this clinical situation. Women presenting with without the classic chest pain during coronary syndrome were less likely to receive timely therapies. This included less fibrinolytics and less primary percutaneous intervention (Canto et al JAMA 2012 and Rogers et al Circulation 2012) Women get the same benefit from PCI but have been shown to have more experience periprocedural complications (Alexander et al Circulation 2006, Regitz-Zagrosek et al Our Heart J 2011 and Dey et al Heart 2009) Women with atypical presentations were also less likely to receive aspirin, other antiplatelet agents, heparin, and beta-blocker therapies during their hospitalization (Canto et al JAMA 2012 and Rogers et al Circulation 2012) Women had a 4% absolute higher in-hospital mortality after presentation with ACS when compared to men (Canto et al JAMA 2012) Women and cardiovascular disease Commission: reducing the global burden by 2030 (Vogel et al Lancet 2021) Conclusion We hope that Dr. Datta's personal journey helps you recognize that gender inequity does exist in the house of medicine. You can appreciate that there are systemic gender inequities in each of the three pillars of EBM and we should be working towards a Humanist-Based Medicine (HBM) model that is inclusive of everyone.  Understand how these gender inequities can have serious impact our clinical management. The example we used was that women with cardiovascular disease were under-diagnosed, under-treated and had worse outcomes compared to men. The SGEM will be back next episode doing a structured critical appraisal of a recent publication. Trying to cut the knowledge translation window down from over ten years to less than one year using the power of social media. The ultimate goal of the SGEM is for patients get the best care, based on the best evidence. REMEMBER TO BE SKEPTICAL OF ANYTHING YOU LEARN, EVEN IF YOU HEARD IT ON THE SKEPTICS’ GUIDE TO EMERGENCY MEDICINE. Additional Reading: Davies RE, Rier JD. Gender Disparities in CAD: Women and Ischemic Heart Disease. Curr Atheroscler Rep. 2018 Sep 4;20(10):51. doi: 10.1007/s11883-018-0753-7. PMID: 30178384 Mehilli J, Presbitero P. Coronary artery disease and acute coronary syndrome in women. Heart 2020;106:487-492. Greenwood BN, Carnahan S, Huang L. Patient-physician gender concordance and increased mortality among female heart attack patients. Proc Natl Acad Sci U S A. 2018 Aug 21;115(34):8569-8574. doi: 10.1073/pnas.1800097115. Epub 2018 Aug 6. PMID: 30082406; PMCID: PMC6112736 Nguyen PK, Nag D, Wu JC. Sex differences in the diagnostic evaluation of coronary artery disease. J Nucl Cardiol. 2011;18(1):144-152. doi:10.1007/s12350-010-9315-2 Lichtman JH, Leifheit EC, Safdar B, Bao H, Krumholz HM, Lorenze NP, Daneshvar M, Spertus JA, D’Onofrio G. Sex Differences in the Presentation and Perception of Symptoms Among Young Patients With Myocardial Infarction: Evidence from the VIRGO Study (Variation in Recovery: Role of Gender on Outcomes of Young AMI Patients). Circulation. 2018 Feb 20;137(8):781-790. doi: 10.1161/CIRCULATIONAHA.117.031650. PMID: 29459463; PMCID: PMC5822747 Mosca L, Benjamin EJ, Berra K, Bezanson JL, Dolor RJ, Lloyd- Jones DM, et al. Effectiveness-based guidelines for the prevention of cardiovascular disease in women–2011 update: a guideline from the American Heart Association. Circulation. 2011;123:1243–62 Bank IEM, de Hoog VC, de Kleijn DPV, et al. Sex-Based Differences in the Performance of the HEART Score in Patients Presenting to the Emergency Department With Acute Chest Pain. J Am Heart Assoc. 2017;6(6):e005373. Published 2017 Jun 21. doi:10.1161/JAHA.116.005373

Date: September 28th, 2021 Reference: Zampieri et al. Effect of Intravenous Fluid Treatment With a Balanced Solution vs 0.9% Saline Solution on Mortality in Critically Ill Patients: The BaSICS Randomized Clinical Trial. JAMA 2021 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. Board certified in Emergency Medicine, Medical Toxicology, Addiction Medicine, Internal Medicine-Critical Care, and Neurocritical Care, Aaron practices full time as a multidisciplinary intensivist. He is the Medical Director of Respiratory Care for Mayo Clinic Arizona and serves proudly as the medical student clerkship director for critical care medicine. Case:  A 66-year-old woman 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 mm Hg.  You wonder which intravenous (IV) fluid should you order? Background: In ten seasons of the SGEM we have not covered the issue of which IV solution is the best in critical ill patients. That includes both trauma patients and septic patients. The controversy has been long standing with the standard joke being that there is nothing “normal” about normal saline. Saline is a hypertonic acidotic fluid. Many critically ill patients receive intravenous crystalloids for volume expansion as part of their resuscitation.  Some bench work, observational studies, and now two large, unblinded, cluster-randomized single-center trials (SMART and SALT-ED) suggested a benefit to using balanced crystalloids (i.e. Lactated Ringer’s or Plasmalyte 148) over 0.9% saline. In the two large trials, this benefit was seen as a reduction in a composite outcome of major adverse kidney events within 30 days (MAKE-30). In the non-blinded SMART trial, there was no statistical difference in the individual components of the composite outcome (in-hospital death before 30 days, new renal replacement therapy or in creatinine >200% of baseline). The SALT-ED trial was also a single-centre unblinded trial, but the primary outcome was hospital free days. They reported no statistical difference between the two groups. Their secondary composite outcome of death, new renal-replacement therapy, or final serum creatinine >200% of baseline, was statistically better with balanced crystalloid vs saline. However, there was not a statistical difference in any of the individual components of the composite outcome. The BaSICS trial attempts to answer whether balanced solutions are superior to saline using a large, double-blind, factorial, multi-center randomized trial. Clinical Question: Does administration of a balanced solution (Plasma-Lyte 148) during intensive care unit (ICU) stay, compared with saline solution, result in improved 90-day survival in critically ill patients? Reference:  Zampieri et al. Effect of Intravenous Fluid Treatment With a Balanced Solution vs 0.9% Saline Solution on Mortality in Critically Ill Patients: The BaSICS Randomized Clinical Trial. JAMA 2021 Population: Adult patients admitted the ICU for more than 24 hours, needing at least one fluid expansion and with at least one risk factor for acute kidney injury (age over 65, hypotension, sepsis, required mechanical ventilation or non-invasive ventilation, oliguria or increased serum creatinine level, cirrhosis or acute liver failure) Exclusions: Required or expected to require renal replacement therapy within 6 hours of admission, severe electrolyte disturbances (sodium < 120 mmol/L or > 160 mmol/L), death considered imminent within 24 hours, suspected or confirmed brain death, palliative or comfort care only or patients previously enrolled in the trial. During the study, hyperkalemia (K+ > 5.5 mEq/L) was removed as an exclusion criteria, after the second interim analysis. Intervention: Plasmalyte 148 solution at either slow (333 mL/hr) or fast (999 mL/hr) infusion rate. Comparison: 0.9% sodium chloride solution at either slow (333 mL/hr) or fast (999 mL/hr) infusion rate. Outcomes: Primary Outcome: 90-day survival Secondary Outcomes: Need for renal replacement therapy up to 90 days after enrollment, occurrence of acute kidney injury, for patients without acute kidney injury at enrollment, SOFA score and, number of days not requiring mechanical ventilation within 28 days Trial Design: Double-blind, factorial, randomized clinical trial conducted at 75 ICUs in Brazil. Authors’ Conclusions: “Among critically ill patients requiring fluid challenges, use of a balanced solution compared with 0.9% saline solution did not significantly reduce 90-day mortality. The findings do not support the use of this balanced solution.” Quality Checklist for Randomized Clinical Trials: The study population included or focused on those in the emergency department. No The patients were adequately randomized. Yes The randomization process was concealed. Yes The patients were analyzed in the groups to which they were randomized. Yes The study patients were recruited consecutively (i.e. no selection bias). Unsure The patients in both groups were similar with respect to prognostic factors. Yes All participants (patients, clinicians, outcome assessors) were unaware of group allocation. Yes All groups were treated equally except for the intervention. No Follow-up was complete (i.e. at least 80% for both groups). Yes All patient-important outcomes were considered. Yes The treatment effect was large enough and precise enough to be clinically significant. Unsure Results: A total of 10,520 patients were randomized and available for analysis. The mean age was 62 years, 44% were female, 48% admitted after elective surgery, 68% had received crystalloid bolus before ICU admission (45% getting > 1 litre), 60% were hypotensive or getting vasopressors, 44% required mechanical ventilation and median volume of fluid was 1.5 litres during the first day of enrollment. Key Results: No significant interaction between fluid type or infusion rate for the primary outcome of death at 90 days. Secondary Outcomes: There were 19 secondary outcomes evaluated. Of those, two met the threshold for statistical significance with both reporting harm with the balanced solution. Specifically, SOFA score at day 7 (absolute difference 0.27 [0.08-0.45]) and neurological SOFA score > 2 at day 7 (32.1% vs 26.0% for the saline solution group; odds ratio, 1.40 [95% CI, 1.18-1.66]). 1) External Validity: This study was conducted in 75 ICUs in Brazil. Half of the patients were admitted after elective surgery and 44% were on mechanical ventilation. The median APACHE II score was 12 and the median SOFA score was 4. Are these the same patients you see in your ICU? 2) Fluids: Almost half of patients had received more than 1 litre of IV fluids prior to enrollment. More of the patients received balanced solution compared to saline solution. This could have impacted the results. The total volume of crystalloids received by patients in the trial was small. The median volume of fluid was 1.5 litres during the first day of enrollment. During the first three days after enrollment the accumulated median fluid administered (including study fluid and non-study fluid) was 4.1 L (SD, 2.9 L) and the median study fluid administered during the same period was 2.9 L (SD, 2.4 L). 3) Power Calculation. The sample size was calculated based on an estimated 90-day mortality of 35% in the saline group. Actual mortality was lower (around 27%) in both groups.  The authors say that this may have resulted in a lower power to observe a clinically important difference. Power calculation is mainly dependent on two things: the effect size, and the sample size. The effect size is the delta, the difference between intervention and the control or comparison group. The sample size is the number of participants in the cohort. You will read papers that say the study was underpowered to find a difference. I’ve probably said this before and been in error. Once you have run the experiment the results are as reported. An assumption was made a priori as to effect size. You no longer have an assumption for the magnitude of effect. Now you have a data set with the “actual” effect size in that population. This is probed for analyzed for statistical significance with the appropriate tools. No more assumptions on effect size needs to be made and what you see is what you get. 4) Secondary Outcomes or Subgroup Analyses: They found two of 19 secondary outcomes that were statistically significant. Both showed increased harm with balanced solution compared to saline The authors say: “all of the subgroup and secondary outcome analyses should be considered as only hypothesis-generating”. The authors are correct that it is hypothesis generating. We should not over-interpret secondary outcomes or subgroups. We have seen in other trials where these statistical differences are highlighted (CRASH-3) because of the potential positive patient impact. I think this could be an example of intervention bias (Foy and Filippone 2013). I doubt we will see people advocating for “normal” saline in the ICU for these secondary outcomes 5) Industry Involvement: Baxter supported this large trial by providing the fluids. There were some financial conflicts of interest declared with some of the authors. However, Baxter did not have a role in the design and conduct of the study. Funding and fCOIs are just additional data points that need to be considered. They occur on a spectrum from no industry involvement to being designed,

Date: September 20th, 2021 Reference: Litell et al. Most emergency department patients meeting sepsis criteria are not diagnosed with sepsis at discharge. AEM 2021. Guest Skeptic: Dr. Jess Monas is a Consultant in the Department of Emergency Medicine at the Mayo Clinic Hospital, Phoenix, Arizona. She is also an Assistant Professor, Department of Emergency Medicine Mayo Clinic Alix School of Medicine in Scottsdale, Arizona. Jess also does the ultra summaries for EMRAP. Case: A 60-year-old man presents to the emergency department with a non-productive cough and increasing shortness of breath.  He has a history of chronic obstructive pulmonary disease (COPD), hypertension (HTN), congestive heart failure (CHF), and benign prostatic hypertrophy (BPH).  He’s afebrile.  He has a heart rate of 93 beats per minute, a blood pressure of 145/90 mm Hg, respiratory rate of 24 breaths per minute, and an oxygen saturation of 92% on room air. Initial labs come back with a slightly decreased platelet count (149) and a minimally elevated creatinine (1.21 mg/dl or 107 umol/L).  He triggers a sepsis alert, and you get a pop-up suggesting IV antibiotics and 30cc/kg of IV fluids.  So, you ask yourself, is this guy really septic and should we bypass those fluids? Background: We have covered sepsis many times on the SGEM since 2012.  This has included the three large RCTs published in 2014-15 comparing early goal-directed therapy (EGDT) to usual care. All three showed no statistical difference between the two treatments for their primary outcome (SGEM#69, SGEM#92 and SGEM#113). There was also SGEM#174 which said don’t believe the hype around a Vitamin C Cocktail that was being promoted as a cure for sepsis and SGEM#207 which showed prehospital administration of IV antibiotics did improve time to get them in patients with suspected sepsis, but did not improve all-cause mortality.  The SGEM was part of a group of clinicians who were concerned about the updated 2018 Surviving Sepsis Campaign (SSC) guidelines. Specifically, the fluid, antibiotics, and pressor requirements within the first hour of being triaged in the emergency department. Despite the lack of high-quality evidence to support these sepsis bundles, many hospitals incorporated them into their electronic medical record (EMR).  They created these sepsis alerts with the intention of identifying septic patients, so they can be treated accordingly.  Most physicians agree that antibiotics should be given early in septic patients.  However, the jury is still out for other interventions with potential for harm, particularly, the infusion of 30cc/kg of IV fluids. Worldwide sepsis contributes to the death of 5.3 million hospitalized people annually.  It is the leading cause of death in the intensive care unit (ICU) in the US and the most expensive diagnosis.  Since 2015, the Centers for Medicare & Medicaid Services (CMS) have indexed the quality of hospital care for sepsis to the SEP-1 core measure.  Interventions, particularly early antibiotics, have been associated with improved mortality. Diagnosing sepsis can be challenging.  To adequately capture patients, specificity has been sacrificed for better sensitivity.  We care more about catching all the true positives and worry less if a few true negatives get mixed up in there.  Using vital signs and lab abnormalities certainly captures more patients, but it also identifies those without an infection.  Patients with cirrhosis, toxicities, those on dialysis.  It is possible that some of these patients can be at risk for harm from one of these interventions. Clinical Question: What proportions of patients meeting sepsis criteria were actually diagnosed with sepsis, and how many non-septic patients had risk factors for harm from aggressive fluid resuscitation? Reference: Litell et al. Most emergency department patients meeting sepsis criteria are not diagnosed with sepsis at discharge. AEM 2021. Population: These were adult ED patients presenting to a tertiary academic medical center who met criteria for Sepsis-3 or Sepsis-3 plus shock. Sepsis-3 was defined as patients with a SOFA score ≥ 2 (Sequential Organ Failure Assessment score) and a suspected infection (which they counted if patients were given IV antibiotics within 24 hours of admission).  Sepsis-3 plus shock was defined as Sepsis-3 with an initial lactate level > 2 and any systolic blood pressure < 90. Excluded: Trauma patients and those with missing ICD-9 codes. This is because prophylactic antibiotics often administered in traumatic or orthopaedic injuries. Intervention: N/A Comparison: They compared those with a sepsis diagnosis at discharge to those without a sepsis diagnosis at discharge. Outcome: Primary Outcome: The primary outcome was proportion of ED patients with suspected sepsis based on consensus criteria who were not diagnosed with sepsis at discharge. Basically, they were initially flagged as potentially septic, but didn’t turn out to be. Secondary Outcomes: Proportion of non-septic patients at risk of harm from the administration of a rapid weight based IV fluid bolus. The risk factors included congestive heart failure, cirrhosis, dialysis-dependent renal failure, and morbid obesity. They also looked at mortality for Sepsis-3 and Sepsis-3 plus patients. Type of Study: Retrospective observational cohort design. Authors’ Conclusions: “Most patients meeting sepsis criteria in the ED were not diagnosed with sepsis at discharge.  This may result in many patients receiving sepsis treatment bundles that has the potential for harm.” Quality Checklist for Observational Study: Did the study address a clearly focused issue? Yes Did the authors use an appropriate method to answer their question? No Was the cohort recruited in an acceptable way? Yes Was the exposure accurately measured to minimize bias? Yes Was the outcome accurately measured to minimize bias? No Have the authors identified all-important confounding factors? No Was the follow-up of subjects complete enough? Yes How precise are the results? Not very Do you believe the results? Yes Can the results be applied to the local population? Unsure Do the results of this study fit with other available evidence? Yes Results: They identified 4,060 patients who received IV antibiotics and had a SOFA ≥ 2. There were 935 patients excluded because of a primary trauma diagnosis and four with missing ICD-9 codes. There were 3,121 patients meeting Sepsis-3 criteria and 1,032 meeting Sepsis-3 plus shock criteria. The mean age was 60 years and 37% were female. Key Results: Most patients meeting sepsis criteria were not diagnosed with sepsis at discharge. Primary Outcome: The proportion of ED patients with suspected sepsis based on consensus criteria who were not diagnosed with sepsis at discharge 75% of patients meeting Sepsis-3 criteria did not receive an explicit diagnosis of sepsis at discharge and about half (52%) did not receive an implicit diagnosis. 52% of patients meeting Sepsis-3 plus shock criteria did not receive an explicit diagnosis of sepsis at discharge and 38% did not receive an implicit diagnosis Secondary Outcome: Proportion of non-septic patients at risk of harm from the protocolized administration of a rapid weight-based crystalloid bolus. About 40% of patients meeting Sepsis-3 criteria and 30% of patients meeting Sepsis-3 plus shock, were not diagnosed with sepsis at discharge, but did have at least one risk factor for harm from large-volume fluid resuscitation. About 30% treated for suspected sepsis, had no infectious etiology found. The most common non-infectious diagnoses were overdose, inhalation pneumonitis, acute respiratory failure (asthma, COPD, CHF), DKA and acute renal failure 9% mortality in Sepsis-3 patients and 16% in Sepsis-3 plus shock patients 1) Retrospective Study Design: The authors used a retrospective method to collect data. The study was not originally designed to answer the question being asked. This retrospective methodology may have both overestimated the patients that would have been considered septic by assuming a normal baseline and underestimated the patients by assuming normal values when data was missing. Sepsis-3 states that the SOFA score should be an increase in organ dysfunction, meaning a change ≥ 2 from baseline.  It appears that the study assumed a normal baseline and assigned sepsis label if SOFA ≥ 2. This leads to uncertainty and greater difficulty in interpreting the data. 2) Diagnosis of Sepsis: How accurate was the diagnosis of sepsis? ICD-10 codes are used for SEP-1 core measures in reporting to CMS.  However, this hospital used ICD-9 codes as the reference standard for the final diagnosis.  This could have led to misattribution bias.  It would have been less likely to occur using explicit codes rather than implicit codes which are comparatively more ambiguous. 3) SOFA Score: The SOFA score has good but not great ability to predict outcomes from sepsis in various populations. (Ferreira 2001, Arts 2005, Jones 2009, Cárdenas-Turanzas 2012, and Miller 2021). Sepsis-3 states that the SOFA score should be an increase in organ dysfunction, meaning a change ≥ 2 from baseline. They assumed a normal baseline which could overestimate the prevalence of sepsis. If data was missing, they assumed normal values and that would underestimate the number of patients with sepsis.  4) Single Center: This was a single center study which can limit the external validity of their findings.  It would depend on how sick the patients were in this study at baseline compared to local populations.  In order to generalize to your demographic, it would be helpful to know what the baseline SOFA score is of this population.  This paper assumed that patients had no organ dysfunction at baseline,

Date: September 16th, 2021 Reference: Sippola et al. Effect of Oral Moxifloxacin vs Intravenous Ertapenem Plus Oral Levofloxacin for Treatment of Uncomplicated Acute Appendicitis. The APPAC II Randomized Clinical Trial. JAMA 2021 Guest Skeptic: Dr. Rob Leeper is an assistant professor of surgery at Western University and the London Health Sciences Center.  His practice is in trauma, emergency general surgery, and critical care with an academic interest in ultrasound and medical simulation. Rules of SGEM Journal Club Case: A 23-year-old man with CT confirmed uncomplicated appendicitis, mild abdominal pain, stable clinical signs, and essentially normal laboratory investigations has just concluded his bedside consultation with the on-call general surgery team.  The patient and surgeons have had an evidence-informed discussion and have arrived at a mutually agreed upon decision to proceed with non-operative treatment of his appendicitis.  The patient is recommended to undergo admission to hospital for serial observation and intravenous antibiotics.  The patient asks; “gosh doc, if this disease is so mild why can’t I just go home and take antibiotics by mouth?”. Dr. Eric Walser Background: The appendix is a structure about as long as your pinkie finger that hangs off the beginning of the colon, in the right lower quadrant of your abdomen. There are lots of theories about subtle functions of the appendix, but its most prominent role is to become inflamed or infected in approximately 7% of people. Usually appendicitis occurs because the lumen, or inside, of the appendix is obstructed by something. Often that is a piece of stool called a fecalith, but other times it can be lymph tissue or another process we may never actually identify. This causes the pressure in the appendix to increase eventually obstructing venous outflow and then arterial inflow. We used to assume that this was an ordered progression that always leads to appendiceal rupture in a stepwise fashion, but we now think that there is more of a spectrum of severity based on individual anatomic and other factors. While the presentation of appendicitis can vary from patient to patient, as our emergency medicine colleagues know well, most patients are not diffusely peritonitic or systemically unwell. Before we had things like surgery or antibiotics, appendicitis carried up to a 50% case fatality rate. Luckily now, with these treatments the mortality rate is almost zero. For the last 135 years we have treated appendicitis with an appendectomy, which is now almost always performed in laparoscopic fashion. A laparoscopic appendectomy involves a general anesthetic, making three small incisions between 1 and 2 cm in length; and the operation usually takes somewhere between 30 to 60 minutes. Most patients go home the same day or the next morning, either with a short course of antibiotics or with none after surgery. Most patients who have this surgery are back to work and their usual routine at around the two-week mark. The chance of requiring additional procedures is quite low unless we find that the appendix has already perforated. It is a good, and generally very safe operation, with a high rate of patient satisfaction. Omar et al  published a study in 2008 showing just how safe laparoscopic appendectomies have become. They found in over 230,000 UK patients the death rate was less than half compared to the open procedure (0.64% vs 0.29%; p<0.001). Patrick Roy Nonoperative treatment of appendicitis (NOTA) was first described in the 1940s and moved into the public consciousness when Patrick Roy was treated with antibiotics alone during the 1994 Stanley Cup playoffs. In 2014, tennis star Rafael Nadal was diagnosed with acute appendicitis. He was participating in the Shanghai Masters Tennis Tournament at the time. Nadal opted to be treated with antibiotics and had his appendix removed via laparoscopic one month later. There have been several randomized trials like the APPAC trial and the CODA trial demonstrating that, in general, nonoperative management is safe, but that 25-60% of patients would go on to require an appendectomy during follow-up, which was usually around one year. The recent Eastern Association for the Surgery of Trauma (EAST) guidelines from 2019 on appendicitis could not provide a recommendation on the use of NOTA as first line treatment. Despite this, we know from database studies that appendectomy remains far more common in North America, with nonoperative management reserved for remote areas or extenuating circumstances. We have covered adult uncomplicated NOTA a couple of times on the SGEM. The first time was on SGEM#115 and we reviewed two SRMAs on the topic that came to opposite conclusions. The other time we looked at this issue was with Dr. Leeper on SGEM#256. We reviewed an observational study on NOTA. SGEM Bottom Line: Nonoperative management of acute uncomplicated appendicitis may be better than we thought in selected patients but comes with a cost of a small absolute increase in some complications. In that observational study by Sceats et al in JAMA 2019, all the patients were admitted to hospital for their antibiotic therapy or surgery. The study we are going to be looking at today compared outpatient vs. inpatient NOTA with antibiotics. Clinical Question: Is a course of oral, outpatient antibiotic treatment non-inferior to a course of initial in-patient, IV antibiotics followed by completion of oral, outpatient antibiotics? Reference: Sippola et al. Effect of Oral Moxifloxacin vs Intravenous Ertapenem Plus Oral Levofloxacin for Treatment of Uncomplicated Acute Appendicitis. The APPAC II Randomized Clinical Trial. JAMA 2021 Population: Healthy adult patients aged 18 to 60 with CT proven, uncomplicated appendicitis without appendicolith. They defined uncomplicated as having an appendiceal diameter larger than 6 mm with a thickened, contrast-enhanced wall along with periappendiceal edema and/or minor fluid collection and the absence of the criteria of complicated acute appendicitis. Complicated was defined as the  presence of appendicolith, perforation, abscess, or suspicion of tumor. Exclusions: They excluded those outside the age range, allergy to contrast media or iodine, allergy on contraindication to antibiotic therapy, kidney insufficiency or elevated serum creatinine level, type 2 diabetes, and use of metformin medication, severe systemic illness (eg, malignancy, medical condition requiring immunosuppressant medication), pregnancy or lactation. Intervention: Oral antibiotics for seven days (moxifloxacin 400mg daily) Comparison: Intravenous IV antibiotics for two days (ertapenem sodium 1 g once daily) followed by oral antibiotics for 5 days (levofloxacin 500 mg a day plus metronidazole 500 mg three times daily) Outcome: Primary Outcome: Success at one-year. This was defined as resolution of acute appendicitis resulting in discharge from the hospital without the need for surgical intervention and no recurrent appendicitis during the 1-year follow-up. Secondary Outcomes: Postintervention adverse events related to antibiotics or appendectomy, abdominal symptoms, duration of hospital stay, pain, and length of sick leave. Authors’ Conclusions: “Among adults with uncomplicated acute appendicitis, treatment with 7 days of oral moxifloxacin compared with 2 days of intravenous ertapenem followed by 5 days of levofloxacin and metronidazole resulted in treatment success rates greater than 65% in both groups, but failed to demonstrate noninferiority for treatment success of oral antibiotics compared with intravenous followed by oral antibiotics.” Quality Checklist for Randomized Clinical Trials: The study population included or focused on those in the emergency department. Yes The patients were adequately randomized. Yes The randomization process was concealed. Yes The patients were analyzed in the groups to which they were treated. No The study patients were recruited consecutively (i.e. no selection bias). Yes The patients in both groups were similar with respect to prognostic factors. Yes All participants (patients, clinicians, outcome assessors) were unaware of group allocation. No All groups were treated equally except for the intervention. Yes Follow-up was complete (i.e. at least 80% for both groups). Yes All patient-important outcomes were considered. No The treatment effect was large enough and precise enough to be clinically significant. Yes Results: They randomized 599 patients, mean age was 36 years, and 44% were female. Key Result: Outpatient oral antibiotics failed to show non-inferiority compared to inpatient IV antibiotics followed by outpatient oral antibiotics. Primary Outcome: The treatment success rate at one year 70.2% outpatient oral vs 73.8% inpatient IV followed by outpatient oral −3.6% difference (1-sided 95% CI, −9.7% to ¥) p = 0.26 Secondary Outcomes: There were no statistical differences in any of the secondary outcomes measured. 1. Exclusions – They excluded pregnant and breastfeeding patients. This is a common exclusion and contributes to the lack of knowledge about how best to treat women (Women and Health Research IOM 1999). If there were concerns regarding lactation, potential participants could have been asked about bottle feeding temporarily during the study period. 2. Participation Rate – There were 1,036 patients eligible to be included in the trial. 433 declined to participate immediately (42%) and 16 more withdrew their consent after randomization. This means that 57% of patients agreed to NOTA. When using a script to explain the pros and cons of NOTA to patients, Minecci et al showed a real-life uptake of about 35% for NOTA in pediatric patients.

Date: September 8th, 2021 Reference: Desch et al. The TOMAHAWK Investigators. Angiography after Out-of-Hospital Cardiac Arrest without ST-Segment Elevation. NEJM 2021. Guest Skeptic: Dr. Stephen Meigher is the EM Chief Resident training with the Jacobi and Montefiore Emergency Medicine Residency Training Program. He heads curriculum and conference for the academic year and is passionate about resident education on- and off-shift, from procedural to evidence-analytical.  Dr. Kaushal Khambhati is also a fourth-year resident training with the Jacobi and Montefiore Emergency Medicine Residency Training Program.  He is interested and experienced in healthcare informatics, previously worked with ED-directed EMR design, and is involved in the New York City Health and Hospitals Healthcare Administration Scholars Program (HASP). Five Rules of the SGEM Journal Club Case: A 70-year-old woman is found unresponsive and apneic at home by her partner.  EMS arrives and finds the patient in monomorphic ventricular tachycardic (VT) cardiac arrest. She has a history of hypertension and non-insulin dependent diabetes mellitus. The paramedics achieve return of spontaneous circulation (ROSC) after CPR, advanced cardiac life support (ALCS), and Intubation.  She arrives in the emergency department (ED) with decreased level of consciousness and shock.  The EKG shows sinus tachycardia with nonspecific changes and no ST segment elevations, Q waves, or hyperacute T waves.  Her point-of-care ultrasound (POCUS) shows appropriate-appearing global ejection fraction and no marked wall motion abnormalities.  Cardiology has been consulted and asks for a neurology consultation given her mental status. Background: The American Heart Association estimates there are approximately 350,000 EMS-assessed out-of-hospital cardiac arrests (OHCAs) in the United States per year. Half of these arrests are witnessed with the other half being un-witnessed. Many of these OHCAs are due to ventricular fibrillation or pulseless VT. Defibrillation is the treatment of choice in these cases but does not often result in sustained ROSC (Kudenchuk et al 2006). Acute coronary syndrome (ACS) is responsible for the majority (60%) of all OHCAs in patients. There is evidence that taking those patients with ROSC and EKG showing STEMI directly for angiography +/- angioplasty is associated with positive patient-oriented outcomes. The AHA has a statement with recommendations based on the available data. They suggest to perform catheterization and reperfusion for post-arrest patients with ST-segment elevation, even if the patient is comatose  However, there is no consensus if this strategy should be employed in patients without ST-segment elevation (Yannopoulos et al, Circulation 2019). The 2015 AHA Guidelines make the following recommendations: Coronary angiography should be performed emergently (rather than later in the hospital stay or not at all) for OHCA patients with suspected cardiac etiology of arrest and ST elevation on ECG (Class I, LOE B-NR). Emergency coronary angiography is reasonable for select (eg, electrically or hemodynamically unstable) adult patients who are comatose after OHCA of suspected cardiac origin but without ST elevation on ECG (Class IIa, LOE B-NR). Lemke et al 2019 published a multicentre RCT done in the Netherlands looking at patients without ST segment elevation in OHCA with ROSC.  Patients were randomized to receive immediate coronary angiography or delayed coronary angiography performed after neurologic recovery. They found no superiority to the immediate strategy for their primary outcome of survival at 90 days. One of the limitations of the COACT trial is they only included patients who had an intra-arrest shockable rhythm which only accounts for 60% of OHCA patients. Clinical Question: Does early coronary artery angiography following resuscitation of Out-of-Hospital Cardiac Arrest benefit patient outcomes in patients without ST Segment elevation patterns on their post-ROSC EKG? Reference: Desch et al the TOMAHAWK Investigators. Angiography after Out-of-Hospital Cardiac Arrest without ST-Segment Elevation. NEJM 2021. Population: Adults aged 30 years and older with shockable or non-shockable OHCA, ROSC and no ST segment elevation EKG pattern. Exclusions: ST-segment elevation or left bundle branch block, no ROSC, severe hemodynamic or electrical instability requiring immediate coronary angiography/intervention (delay clinically not acceptable), life-threatening arrhythmia possibly caused by acute myocardial ischemia, cardiogenic shock (defined by clinical and hemodynamic criteria), obvious extra-cardiac etiology such as traumatic brain injury, primary metabolic or electrolyte disorders, intoxication, overt hemorrhage, respiratory failure due to known lung disease, suffocation, drowning, IHCA and known or likely pregnancy Intervention: Immediate angiography as soon as possible after hospital admission Comparison: Delayed or selective angiography after being transferred to the intensive care unit (ICU) for further evaluation of the cause of the cardiac arrest and for treatment Outcome: Primary Outcome: All-cause mortality at 30 days Secondary Outcomes: They had 13 secondary endpoints of which only 7 of the 13 were reported in the published manuscript. Reported: MI at 30 days, severe neurologic injury (Cerebral Performance Category of 3-5) at 30 days, composite of death from any cause at 30 days or severe neurologic deficit at 30 days, ICU length of stay (LOS), serialized values for the Simplified Acute Physiology Score (SAPS) II, rehospitalization for CHF within 30 days, and peak values of myocardial biomarkers. Not Reported: MI at 6 and 12 months, severe neurologic injury at 6 and 12 months, all-cause mortality at 6 and 12 months, rehospitalization for CHF at 6 and 12 months, LOS in hospital, and quality of life at 6 and 12 months Adverse Events: Moderate or severe bleeding (Types 2-5 on Bleeding Academic Research Consortium), stroke at 30 days, and acute kidney failure requiring hemodialysis at 30 days Authors’ Conclusions: “In this randomized, international trial, we found that among patients with successfully resuscitated out-of-hospital cardiac arrest and no ST- segment elevation, a strategy of immediate unselected coronary angiography provided no benefit over a delayed and selective approach with respect to the primary end point of death from any cause.”  Quality Checklist for Randomized Clinical Trials: The study population included or focused on those in the emergency department. Yes The patients were adequately randomized. Yes The randomization process was concealed. Yes The patients were analyzed in the groups to which they were randomized. Yes The study patients were recruited consecutively (i.e. no selection bias). Unsure The patients in both groups were similar with respect to prognostic factors. Yes All participants (patients, clinicians, outcome assessors) were unaware of group allocation. No All groups were treated equally except for the intervention. Unsure Follow-up was complete (i.e. at least 80% for both groups). Yes All patient-important outcomes were considered. Yes The treatment effect was large enough and precise enough to be clinically significant. No Results: There were 554 patients recruited and available for analysis in this trial. The median age was 70 years, 70% were male and more than 1/3 (37.6%) had known coronary artery disease. Many patients had comorbidities with the most common being hypertension (68%), dyslipidemia (38%) and diabetes (29%). The median time to ROSC was 15 minutes. Most patients (55%) had a shockable arrest rhythm. The median Glasgow Coma Scale (GCS) score was 3. Angiography was performed in 96% of patients in the immediate group (median time 2.9 hours) and 62% in the delayed/selective group (median time 46.9 hours). Key Result: No statistical difference in all-cause mortality at 30 days  Primary Outcome: All-cause mortality at 30 days 54% immediate group vs 46% delayed/selective group Hazard ratio 1.28 (95% CI; 1.00 to 1.63) Secondary Outcomes:  No statistical difference in incidence of MI, severe neurologic deficit, ICU LOS, SAPS II score, rehospitalization for CHF or peak laboratory results (troponin or creatinine) Composite outcome of all-cause mortality or severe neurologic deficit was greater in the immediate group RR 1.16 (95% CI; 1.00 to 1.34) Adverse Events: No statistical difference in moderate or severe bleeding, stroke or acute kidney failure leading to renal replacement 1. Selection Bias – There could have been some selection bias introduced into the recruitment of patients. Specifically, some of the exclusion criteria required clinical judgement. Examples of this include severe hemodynamic or electrical instability requiring immediate coronary angiography/intervention (delay clinically not acceptable), life-threatening arrhythmia possibly caused by acute myocardial ischemia, and cardiogenic shock (defined by clinical and hemodynamic criteria). It is unclear if this would have had a material impact on the results. One group that was explicitly excluded was those patients known or likely to be pregnant. This sex bias was discussed on a recent SGEM Xtra: Unbreak My Heart. We provided evidence that cardiovascular disease among women is understudied, under-recognized, underdiagnosed, undertreated and women are under-represented in clinical trials. 2. Non-Blinded - This was an open-label study because of the overt nature of coronary angiography. Clinicians would have known which group each patient was assigned. The patient would not be aware of group allocation because they were unconscious with a median GCS score of 3.

Date: August 31st, 2021 Reference: McLean et al. Interphysician weight bias: A cross-sectional observational survey study to guide implicit bias training in the medical workplace. AEM Sept 2021 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 in the emergency department (ED) with the new resident, one of whom is overweight. You overhear his colleagues wonder where he went, chuckling, and one of them comments that “he probably went for second breakfast.” Realizing that these residents are making fun of their colleague’s weight, you decide to address the issue. Background: We have talked about biases many times on the SGEM. Usually when we use the term bias it is in the context of something that systematically moves us away from the “truth”. Science does not make truth claims and the term is used as a shorthand for the best point estimate of an observed effect size. An example in the medical literature would be selection bias. This is when subjects for a research study are not randomly selected. This can skew the results and impact the conclusions.  Another example would be publication bias. Studies with “positive” results are more likely to be published while those with “negative” results are more likely to end up in the bottom of the file drawer. There are many other types of bias in the practice of medicine. Some of my favourite ones are anchoring bias, base-rate neglect, and hindsight bias. For a description of these and many more check out Dr. Pat Croskerry list of 50 cognitive biases in medicine. You can also click on the codex for an extensive list of different biases. This SGEM episode focuses on a kind of bias as defined by the common English language as “a particular tendency, trend, inclination, feeling, or opinion, especially one that is preconceived or unreasoned”. It is a sense of prejudice or stereotyping and the formation of a foregone conclusion independent of current evidence. There are many biases in the house of medicine. We have discussed some of them on  the SGEM. They include things like age, gender, socioeconomic status, race, and other factors. The gender pay gap is one of the topics that has been spoken about most on the SGEM. A paper by Wiler et al AEM 2019 showed females in academic emergency medicine were paid ~$12,000/year less than their male colleagues (SGEM#248). The September 2021 issue of AEM is a special issue focusing on biases in emergency medicine. It includes articles on racial, ethnic and gender disparities. One specific topic jumped out as something that has not received much attention, weight bias. There is literature on physicians’ weight biases towards patients and patients’ weight bias towards physicians. However, there is limited information on physician-to-physician weight bias. Clinical Question: What is the prevalence of interphysician implicit, explicit, and professional weight bias? Reference: McLean et al. Interphysician weight bias: A cross-sectional observational survey study to guide implicit bias training in the medical workplace. AEM Sept 2021 Population: Practicing physicians and physicians-in-training in North America Excluded: Those who did not consent; did not identify as physicians or physicians-in-training; or were not currently residing in North America. Intervention: Survey instruments measuring implicit weight bias (IWB), explicit weight bias (EWB), and professional weight bias (PWB) Comparison: None Outcome: Descriptive analyses along with correlative models Dr. Mary McLean This is an SGEMHOP episode which means we have the lead author on the show. Dr. Mary McLean is an Assistant Program Director at St. John’s Riverside Hospital Emergency Medicine Residency in Yonkers, New York. She is the New York ACEP liaison for the Research and Education Committee and is a past ALL NYC EM Resident Education Fellow. Dr. McLean was the guest skeptic on the SGEM#310 reviewing an article showing EM physicians are not great at performing the HINTS exam. Implicit Bias: Implicit bias is unconscious and often subtle type of bias that is hard to pinpoint in ourselves and notoriously hard to measure. Implicit weight bias (IWB) was measured using the Implicit Association Test (IAT) based on work from Project Implicit which is a Harvard-based research organization. The weight bias IAT has been previously validated for the general population. This was adapted by adding the theme of physicians in the medical workplace. Project Implicit’s silhouette images of people with obesity was modified to add stethoscopes and clipboards, and adjust clothing to look like scrubs, white coats, or professional clothing. The good and bad layperson descriptor words were also replaced with words used to describe good and bad doctors, based on Stern's medical professionalism framework Explicit Bias: Explicit bias is a more outward bias expressed in words or actions, that’s easier for us to pinpoint in other people and in ourselves The Anti-fat Attitudes Questionnaire (Crandall et al 1994), which was originally validated for the general population was the tool used to assess explicit weight bias (EWB). It was adapted to focus on interphysician views and practices. The adapted items were kept as similar as possible to the validated original - for example, only changing the word “person” to the word “doctor” and leaving the remainder of the item unchanged, unless another tweak was absolutely necessary. NOTE: The word “fat” as a descriptor is used in the questionnaire and to investigate explicit and professional weight bias. This word can be inflammatory, but it’s used with purpose. It’s meant to evoke an emotional response from subjects, which is necessary for this kind of research. Physicians were asked 13 questions on a 7-point Likert scale (1- strongly agree, 2- agree, 3- somewhat agree, 4- neither agree or disagree, 5- somewhat disagree, 6- disagree and 7- strongly disagree). Professional Bias: Professional bias was defined as the reduced willingness to collaborate with, seek advice from, and foster mutually beneficial professional relationships with physician colleagues with obesity. To assess professional weight bias (PWB) a new scale of explicit questions that applied specifically to the medical workplace and nuances of physician careers was created. Subjects were asked to used the same Likert scale to rate their agreement with several items. Each item was meant to capture participants’ views on physicians with obesity regarding collaboration, hiring, promotion, leadership opportunities, and other classic measures of professional success determined by group consensus within our team. Authors’ Conclusions: “Our findings highlight the prevalence of interphysician implicit WB; the strong correlations between implicit, explicit, and professional WB; and the potential disparities faced by physicians with obesity. These results may be used to guide implicit bias training for a more inclusive medical workplace.” Quality Checklist for Observational Study: Did the study address a clearly focused issue? Unsure Did the authors use an appropriate method to answer their question? Unsure Was the cohort recruited in an acceptable way? Yes Was the exposure accurately measured to minimize bias? Yes Was the outcome accurately measured to minimize bias? Yes Have the authors identified all-important confounding factors? Unsure Was the follow up of subjects complete enough? Yes How precise are the results? Fairly accurate Do you believe the results? Yes Can the results be applied to the local population? Unsure Do the results of this study fit with other available evidence? Yes Results: Surveys were electronically sent to individuals of which 1,198 opened the document. There were 620 participants who completed the survey. The mean age was 44 years, 58% identified as female, mean BMI was 26, 73% were Caucasian, 78% emergency physicians and 72% were attending physicians. Key Result: A high percentage of participants indicated IWB against other physicians while other results suggested some EWB and PWB does exist. Implicit Weight Bias (IWB): 87% of participants had a D-score above 0, indicating implicit weight bias against other physicians(34% demonstrated severe anti-fat weight bias and 31% moderate) Male and increased age were both positively correlated with anti-fat weight bias Explicit Weight Bias (EWB) and Professional Weight Bias (PWB): Ranges and means on the rating scales showed levels of variability, suggested bias does exist Positive correlation was seen with IWB (r=0.24 for EWB, r=0.16 for PWB) r=0.73 correlating EWB to PWB Male sex positively correlated with both EWB and PWB 1. Correlative Measurements: A lot of correlative measurements were used. Can you explain some of the differences between a D score, r value, B value, and β values? The D-score is a standardized difference calculated from IAT response time data. It ranges from (-1) to (+1), with 0 representing neutrality. In simple terms, a positive D score means you sorted faster when pictures of physicians with obesity were paired with negative words, and slower when physicians with obesity were paired with positive words. This is interpreted as representing implicit bias, with a (+1) indicating maximal anti-fat bias. The opposite is true for negative D scores, with (-1) indicating maximal anti-thin bias. The r value represents strength of correlations. It also ranges from (-1) to (+1), with 0 representing no association, (-1) representing maximal negative association, and (+1) representing maximal positive association.

Date: August 27th, 2021 Reference: Gagnon et al. Direct-access physiotherapy to help manage patients with musculoskeletal disorders in an emergency department: Results of a randomized controlled trial. AEM 2021 Dagny Haas Guest Skeptic: Dagny Kane-Haas is a physiotherapist who also has a master’s degree in Clinical Science in Manipulative Therapy. Case: A forty-year-old woman presents to the emergency department (ED) with a sore lower back after moving some boxes at home over the weekend. She tried acetaminophen with limited relief. Her pain is eight out of ten on the zero-to-ten-point numeric pain rating scale (NPRS). She has no red flags (TUNA FISH) and is diagnosed as having mechanical back pain without imaging as per ACEP Choosing Wisely. You know mechanical low back pain is difficult to treat effectively and are trying to set expectations. While preparing her for discharge you wonder if seeing a physiotherapist before going home from the ED would improve her outcome. Background: Acute and chronic back pain has been covered many times on the SGEM. There is no high-quality evidence that acetaminophen, NSAIDS, steroids, diazepam, muscle relaxants or combinations of pharmacologic modalities provide much relief. SGEM#87:Let Your Back Bone Slide (Paracetamol for Low-Back Pain) SGEM#173: Diazepam Won’t Get Back Pain Down SGEM#240: I Can’t Get No Satisfaction for My Chronic Non-Cancer Pain SGEM#304: Treating Acute Low Back Pain – It’s Tricky, Tricky, Tricky We do know that opioids are very effective at reducing many types of pain including muscular skeletal pain. However, opioids have many side effects and concerns about substance misused. The ACEP 2020 clinical policy on the use of opioids states: “Preferentially prescribe nonopioid analgesic therapies (nonpharmacologic and pharmacologic) rather than opioids as the initial treatment of acute pain in patients discharged from the emergency department. For cases in which opioid medications are deemed necessary, prescribe the lowest effective dose of a short-acting opioid for the shortest time indicated.” (Level C Recommendation) There are several non-pharmaceutical treatments that have also been tried to treat low back pain. They include: Cognitive Behavioural Therapy 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). None of these other treatments has high-quality evidence supporting their use. We have covered a randomized control trial looking at acupuncture to treat painful conditions presenting to the ED, including acute back pain, on SGEM#187. That trial reported no difference in clinical or statistical relevant reduction of pain at one hour between groups (acupuncture only, acupuncture plus pharmacotherapy or pharmacotherapy alone). However, we have not done a structured critical appraisal of an RCT looking at physiotherapy for this clinical condition. Clinical Question: Does access to a physiotherapist in ED help patients who present with minor musculoskeletal disorders (MSKD)? Reference: Gagnon et al. Direct-access physiotherapy to help manage patients with musculoskeletal disorders in an emergency department: Results of a randomized controlled trial. AEM 2021 Population: Adult patients 18-80 years of age presenting to the ED with suspected minor MSKD, traumatic or not. Minor was defined using the Canadian Triage and Acuity Scale (CTAS) score of 3, 4 or 5. Excluded: Non-minor MSKD (ex: open fractures or open wounds), red flags, clinically unstable, hospitalized patients, or those in long-term care facilities. Intervention: Physiotherapist evaluated the patient post triage in the ED. They would recommend interventions based on their clinical assessment. This could include advice, technical aids, imaging, prescribed or over-the-counter medication, and consults with other health care professionals. However, there was no follow-up by the physiotherapist. Comparison: Usual care Outcome: Primary Outcome: Pain and function at one and three months. Pain was assessed using a NPRS. Function was evaluated using the Pain inventory subscale of the short version of the Brief Pain Inventory (BPI). The BPI scores ten activities of daily living (e.g., general activity, mood, walking, work, sleep) on a zero-to-ten-point scale (0 - no interference with function and 10- completely interferes with function) Secondary Outcomes: Utilization of resources at ED discharge, interventions utilized, medications, healthcare professionals consulted, return ED visits and imaging received. Authors’ Conclusions: “Patients presenting with a MSKD to the ED with direct access to a PT had better clinical outcomes and used less services and resources than those in the usual care group after ED discharge and up to 3 months after discharge.” Quality Checklist for Randomized Clinical Trials: The study population included or focused on those in the emergency department. Yes The patients were adequately randomized. Yes The randomization process was concealed. Yes The patients were analyzed in the groups to which they were randomized. Yes The study patients were recruited consecutively (i.e. no selection bias). No The patients in both groups were similar with respect to prognostic factors. No All participants (patients, clinicians, outcome assessors) were unaware of group allocation. No All groups were treated equally except for the intervention. Yes Follow-up was complete (i.e. at least 80% for both groups). No All patient-important outcomes were considered. No The treatment effect was large enough and precise enough to be clinically significant. No Results: They recruited 78 patients into the trial. The mean age was 40 years and 56% were male. Key Result: Lower pain scores and better function in the physiotherapy group compared to usual care at both one and three months. Primary Outcome: Pain (NPRS) and function (BPI) Secondary Outcomes: Control Compared to Physical Therapy (PT). Not applicable (NA), not statistically different (NSD) and over the counter (OTC) medications 1. Consecutive Patients: This was a consecutive recruitment of a convenience sample. The recruitment was only 13 hours per week between the hours of 1pm and 9pm Monday to Friday depending on the physiotherapists schedule. In contrast, emergency medicine is 24/7/365. This selective recruitment could introduce bias and impact external validity to those patients who present on nights, weekends, and holidays. 2. Differences in Groups: Those in the control group were older, more often male and had a higher initial pain score. These differences could have been a result of the block randomization process used to balance area of body affected and not age or sex. The authors did try to control for these factors in their analysis. 3. Lack of Blinding: They did not describe the extent of blinding in the trial. The participants would have known they were seeing a physiotherapist. It is unclear if they were familiar with the hypothesis. It is also not reported if the clinicians were blinded. This lack of blinding could have introduced bias. Getting more attention during the initial visit from another health care professional could have impacted their initial pain and function scores and possibly those at one and three months. If the clinicians knew about the trial they could have altered their usual care. 4. Small Sample Size with Large Loss to Follow-Up: The a priori sample size was calculated on the minimum clinically important difference (MCID) of the BPI estimated to be 1.00. This required a total of 90 patients to be recruited into the trial. The final cohort consisted of 78 patients. They did not reach their target number of patients due to a lack of funds. A quality metric we look for is less than 20% loss to follow-up. They had about 20% loss to follow-up at the 1-month and 3-month outcome. There were differences in those who sex, age and initial pain scores in those that were lost to follow-up and those who were not. This makes me more skeptical of the results. 5. Outcomes:  They had four primary outcomes with pain and function being assessed at one and three months. This increases the chance of a Type I error where the null hypothesis is falsely rejected (false positive). The point estimate of effect size difference between groups was statistically significant. However, the 95% confidence interval for minimally important clinical difference was crossed for both pain and function at one and three months. Given the multiple other threats to validity (small convenience sample, baseline difference, lack of blinding and loss to follow-up) makes us more skeptical that there is a meaningful clinical difference. Comment on Authors’ Conclusion Compared to SGEM Conclusion: While the conclusions are correct, we think they are incomplete. It would have been better to put in a caution statement about the small sample size, lack of blinding and loss to follow-up to put the conclusions in context. SGEM Bottom Line: Physiotherapy looks promising as a potential intervention for patients with mild MSKD presenting to the ED, but we need better trials to confirm these preliminary findings with clinically significant outcomes before recommending their implementation. Case Resolution: You recommend ibuprofen 400mg to see if that works better than the acetaminophen and try to set reasonable expectations. Clinical Application: It is nice to see an RCT done looking at PT in ED and getting a positive outcome. However, these results need to demonstrate a clinically meaningful outcome and confirmed before applying clinically. Dr. Ken Milne What Do I Tell the Patient?

Date: August 19th, 2021 Reference: Pantell et al. Evaluation and management of well-appearing febrile infants 8 to 60 days old. Pediatrics 2021 Guest Skeptic: Dr. Dennis Ren is a pediatric emergency medicine fellow at Children’s National Hospital in Washington, DC. Case: A 25-day-old, full-term boy presents to the emergency department with fever. His parents report that he felt warm that evening, and they found that he had a rectal temperature of 38.2°C (100.8°F). He has an older sister at home with a cough and rhinorrhea. Overall, he has no symptoms and appears well. He has continued to feed normally and produce wet diapers. The parents ask you, “Do you really think he needs any additional testing? He probably caught something from his sister, right?” Background: Parents often bring their infants to the ED with concerns about fever. They can develop a real “fever fear” or “feverphobia” and often need reassurance that fever alone is not dangerous. We have talked about pediatric fever and fever fear with Dr. Anthony Crocco from Sketchy EBM back on SGEM#95 and made a “Ranthony” video on the topic. The American Academy of Pediatrics says that “…fever, in and of itself, is not known to endanger a generally healthy child.  In contrast, fever may actually be of benefit; thus, the real goal of antipyretic therapy is not simply to normalize body temperature but to improve the overall comfort and well-being of the child.”  However, fever without source in infants less than three months of age represents a significant diagnostic dilemma for clinicians. Several clinical decision instruments had been developed previously, including the Rochester (Jaskiewicz et al 1994), Boston (Baskin et al 1992) and Philadelphia (Baker et al 1993) criteria to help clinicians stratify the risk of significant bacterial infections. A new clinical decision instrument called the Step-by-Step approach was reviewed on SGEM#171. SGEM#171 Bottom Line: If you have availability of serum procalcitonin measurement in a clinically relevant time frame, the Step-by-Step approach to fever without source in infants 90 days old or younger is better than using the Rochester criteria or Lab-score methods. With the caveat that you should be careful with infants between 22-28 days old or those who present within two hours of fever onset. We have been trying to optimize our approach to evaluating and managing febrile infants for more than four decades.  Our goal is to identify the febrile infants with urinary tract infection, bacteremia, and bacterial meningitis (or what was referred to as serious bacterial infections) while simultaneously trying to spare them from invasive and potentially unnecessary procedures like lumbar punctures or the possible iatrogenic consequences of empiric antibiotics or hospitalization. Several risk stratification tools have been published over the years. These clinical decision instruments included subjective clinical criteria along with pre-determined thresholds for lab criteria like white blood cell count (WBC) and immature to total neutrophil ratio. Unfortunately, these criteria may not be appropriate in the current era. In fact, the Modified Boston and Philadelphia Criteria for invasive bacterial infections may misclassify almost one-third of infants with bacterial meningitis. With routine screening of pregnant women, improvements in food safety, and conjugate pneumococcal vaccines, we have seen a decrease in Group B streptococcus, Listeria, and Streptococcus pneumoniae infections in infants. Instead, there has been a shift to Gram-negative organisms being the most common culprits in bacterial infections in infants. Simultaneously, our ability to test for infection has advanced with the use of inflammatory markers (IM) like procalcitonin and C-reactive protein (CRP) as well as polymerase chain reaction (PCR) testing for rapid identification of multiple viruses and bacteria. Clinical Question: What are recommendations for evaluating and managing well-appearing, term infants, 8 to 60 days of age with fever ≥38°C? Reference: Pantell et al. Evaluation and management of well-appearing febrile infants 8 to 60 days old. Pediatrics 2021 Authors’ Conclusion: “Three algorithms summarize the recommendations for infants 8 to 21 days of age, 22 to 28 days of age, and 29 to 60 days of age. The recommendations in this guideline do not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate.” Quality Checklist for A Guideline: The study population included or focused on those in the emergency department? No An explicit and sensible process was used to identify, select and combine evidence? Yes The quality of the evidence was explicitly assessed using a validated instrument? Yes An explicit and sensible process was used to the relative value of different outcomes? Yes The guideline thoughtfully balances desirable and undesirable effects? Yes The guideline accounts for important recent developments Yes/Unsure The guidelines has been peer-reviewed and tested? Yes/No Practical, actionable, and clinically important recommendations are made? Yes The guideline authors’ conflicts of interest are fully reported, transparent and unlikely to sway the recommendations of the guidelines? Yes Key Recommendations: There are four key components to considered in evaluating the well-appearing febrile infant and three algorithms based on the age of the infant. Four Key Components of Evaluation: Urine Blood culture Inflammatory Markers (IM) Procalcitonin >0.5 ng/mL Absolute neutrophil count (ANC) > 4,000 mm3 or >5,200 mm3 (There are two ANC cutoffs included based on the PECARN study and Febrile Young Infant Research Collaborativestudy) CRP >20 mg/L Temperature > 38.5°C Cerebrospinal Fluid (CSF) from lumbar puncture (LP) Algorithms At a Glance: There are three age groups (8-21d, 22-28d and 29-60d). All age groups get urine and blood cultures. Inflammatory markers are considered optional for the youngest group. The youngest group gets an LP, antibiotics and admitted while the older two groups may get an LP and antibiotics and may be discharged home. Infants 8 to 21 Days of Age This is a straightforward group and not a big change from previous practice. We should still be conservative with this group. These infants are all getting a full work up including urine, blood, and CSF. They are being treated with empiric antibiotics and staying in the hospital. Dr. Archie Cochrane The inflammatory markers are optional (Grade B, Weak Recommendation) as they do not really change decision to administer antimicrobials or disposition. This follows Archie Cochrane’s approach to testing: “Before ordering a test, decide what you will do if it is (1) positive or (2) negative. If both answers are the same, don’t take the test”. We should be also cautious regarding herpes simplex virus (HSV) infection in this age group and may also consider adding acyclovir coverage in addition to empiric antibiotics. Infants 22 to 28 Days of Age This is where there is some nuance and room for shared decision making. We are still going to obtain urine and blood. This is where the inflammatory markers can be used to guide further management. If any IM is abnormal, these guidelines recommend performing an LP and obtaining CSF (Grade C, Moderate Recommendation). However, even if all IMs are normal, the clinician can still choose to perform a LP. If the decision is made to defer LP, these patients will need to stay in the hospital. The choice of administering empiric antimicrobials in a situation where an LP is not performed is dependent on a discussion of the potential harms and potential benefits between clinician and family. While the risk of meningitis is lower in this age group, empiric treatment without CSF may result in partially treated meningitis. A key thing to remember for this algorithm and age group is that we should not send these patients home without obtaining an interpretable CSF. If the urine studies are normal, IM are normal, CSF is normal or enterovirus positive, these patients can be discharged home after receiving a dose of parenteral antibiotics (Grade C, Moderate Recommendation) with proper anticipatory guidance and return precautions and follow up in 24 hours. Infants 29 to 60 Days of Age This algorithm has the potential to really decrease the number of LPs and allow us to send more infants home based on the IMs. We are still going to start by obtaining urine, blood culture, and IMs. Circumcised boys may be exempted from urine studies given their risk of urinary tract infection is <1%. In the setting of having normal IMs, LP may be deferred (Grade B, Moderate Recommendation) even with a positive urinalysis. Patients with positive urinalysis and normal IMs can be discharged home on oral antibiotics with close follow up in 12 to 24 hours. If urinalysis is negative and the IMs are normal, these patients may be sent home without a lumbar puncture and without antimicrobial therapy. They should be closely observed, provided with strict return precautions, and have follow up arranged within 24 to 36 hours. If the IMs are elevated, things get a bit tricky. The guidelines state that a LP may be performed (Grade C, Weak Recommendation). This is different from the previous age group where the recommendation was that LP should be performed in the setting of abnormal IMs. If CSF is negative with positive or negative urinalysis, you may give them a dose of antimicrobial and still send them home. If CSF is not obtained or uninterpretable, you should give a dose of IV antimicrobial and observe in the hospital or discharge home.

Date: August 12th, 2021 Reference: Daya et al. Survival After Intravenous Versus Intraosseous Amiodarone, Lidocaine, or Placebo in Out-of-Hospital Shock-Refractory Cardiac Arrest. Circulation 2020 Guest Skeptic: Missy Carter is a PA practicing in emergency medicine in the Seattle area and an adjunct faculty member with the Tacoma Community College paramedic program. Missy is also now the director for Difficult Airway EMS course in Washington State Case: An EMS crew arrives to your emergency department (ED) with a 58-year-old female who suffered a witnessed ventricular fibrillation (VF) out-of-hospital cardiac arrest (OHCA). They performed high-quality CPR and shocked the patient twice before giving amiodarone via intraosseous (IO). After giving hand off the medic tells you she had difficulty finding intravenous (IV) access and went straight to an IO. She wonders if she should have spent more time on scene trying to get the IV versus the tibial IO she has in place. Background: We have covered OHCA multiple times on the SGEM. This has included the classic paper from Legend of EM Dr. Ian Stiell on BLS vs. ACLS (SGEM#64), the use of mechanical CPR (SGEM#136), and pre-hospital hypothermia (SGEM#183). ALPS Trail The issue of amiodarone vs lidocaine has also been covered on SGEM#162. This was the ALPS randomized control trial published in NEJM 2016. The bottom line from that SGEM critical appraisal was that neither amiodarone or lidocaine were likely to provide a clinically important benefit in adult OHCA patients with refractory VF or pulseless ventricular tachycardia. We did do an episode on IO vs IV access for OHCA (SGEM#231). This was a critical appraisal of an observational study published in Annals of EM (Kawano et al 2018). The key result was that significantly fewer patients had a favorable neurologic outcome in the IO group compared to the IV group. However, we must be careful not to over-interpret observational data. There could have been unmeasured confounders that explained the difference between the two groups. In recent years there has been an effort to lower the cognitive load in the pre-hospital setting and focus resources on the interventions that positively effect patient outcomes. There has been a trend to place supraglottic devices over intubation with some evidence to support this move (SGEM#247).  Another trend is to use IO access over IV access to free up pre-hospital providers to focus on more meaningful interventions. Clinical Question: Does it matter if you give antiarrhythmic medications via IV or IO route in OHCA? Reference: Daya et al. Survival After Intravenous Versus Intraosseous Amiodarone, Lidocaine, or Placebo in Out-of-Hospital Shock-Refractory Cardiac Arrest. Circulation 2020 Population: Adult patients with non-traumatic out-of-hospital cardiac arrest and shock refractory ventricular fibrillation or pulseless ventricular tachycardia after one or more shocks anytime during resuscitation. Excluded: Patients who had already received open-label intravenous lidocaine or amiodarone during resuscitation or had known hypersensitivity to these drugs Intervention: Amiodarone, Lidocaine or placebo given IO Comparison: Amiodarone, lidocaine or placebo given IV Outcome: Primary Outcome: Survival to hospital discharge Secondary Outcomes: Survival to hospital admission, survival with favorable neurologic outcome (modified Rankin Scale score of 3 or less) Authors’ Conclusions: We found no significant effect modification by drug administration route for amiodarone or lidocaine in comparison with placebo during out-of-hospital cardiac arrest. However, point estimates for the effects of both drugs in comparison with placebo were significantly greater for the intravenous than for the intraosseous route across virtually all outcomes and beneficial only for the intravenous route. Given that the study was underpowered to statistically assess interactions, these findings signal the potential importance of the drug administration route during resuscitation that merits further investigation. Quality Checklist for Observational Study: Did the study address a clearly focused issue? Yes Did the authors use an appropriate method to answer their question? Yes Was the cohort recruited in an acceptable way? Yes Was the exposure accurately measured to minimize bias? Yes Was the outcome accurately measured to minimize bias? Yes Have the authors identified all-important confounding factors? Unsure Was the follow up of subjects complete enough? Yes How precise are the results? There were wide 95% CI around the point estimate of risk ratios Do you believe the results? Yes Can the results be applied to the local population? Yes Do the results of this study fit with other available evidence? Yes Results: In the ALPS publication, there were 37,889 patients with non-traumatic out-of-hospital cardiac arrest of which 7,051 (18.6%) had shock-refractory ventricular fibrillation or pulseless ventricular tachycardia. The intention to treat (ITT) population was 4,653 and the per-protocol (PP) population was 3,026. There was no statistical difference between Amiodarone (24.4%), lidocaine (23.7%) and Placebo (21.0%) in the ALPS study. There was also no statistical difference in favourable neurologic function at discharge between groups. This was a pre-specified subgroup analysis of the 3,019 PP population. IV route was used 78% of the time and the IO route was used 22% of the time. The mean age of participates was 63 years, 80% were male, less than a 1/3 occurred in a public location, 60% had bystander-initiated CPR and a time to first arrival of EMS of 6 minutes. There were differences in sex, time-to-emergency medical services arrival, and some cardiopulmonary resuscitation characteristics between those in the IO cohort vs. the IV cohort but were similar in other aspects. Key Result: There was no significant effect modification by drug administration route (IV or IO) for amiodarone or lidocaine in comparison with placebo during adult OHCA. Primary Outcome: Survival to hospital discharge Only amiodarone vs. placebo IV was statistically significant (p=0.014) * Adjusted Risk Ratio was 1.26 [95% CI, 1.06–1.50] for IV amiodarone vs placebo No statistical difference for amiodarone or lidocaine compared to placebo when given IO   Secondary Outcomes: Survival to Hospital Admission: Greater if drugs were given by IV compared to placebo but not with IO Survival with Favorable Neurologic Outcome: Greater if drugs were given IV compared to placebo but not with IO 1) Observational Study: This is a subgroup analysis of the ALPS trial which makes it an observational study. The authors properly prespecified their subgroup and reported their data as unadjusted and adjusted which decrease the chance of finding spurious outcomes. However, prespecifying subgroups and adjusting the data cannot overcome the lack of randomizations. We can only conclude associations from this study and not attribute causation to any of the findings. 2) Subgroup Analysis: We should generally view subgroup analyses as hypothesis generating. Very few claims from RCT subgroups get tested in future trials. A study by Wallach et al found that of 117 subgroup claims from RCT only ten percent were tested in a future study. Of those subgroup claims that were tested, zero percent confirmed the original claim. “The overall trial result is usually a better guide to the direction of effect in subgroups than the apparent effect observed within a subgroup” (Yusuf et al JAMA 1991 3) Pharmacologic Characteristics: The authors posit that some differences between lidocaine and the more lipophilic amiodarone might decrease the efficacy of IO vs IV administration.While interesting, we should remember that it is easy to fool ourselves with these types of explanations. The body is very complicated and there is much we do not understand. Such a claim would need to be demonstrated with evidence. 4) Per-Protocol Analysis: The more conservative method of analyzing a superiority trial would have been to do an ITT analysis. Doing a PP analysis can increase the point estimate of effect size. Even with this bias the PP analysis did not demonstrate a statistical difference in primary outcome for the APLS trial. The ITT analysis for the ALPS trial can be found in their supplemental material. It reported no significant differences between the trial groups in the primary or the secondary outcomes. Unfortunately, they did not provide the data broken down by IV vs IO. 5) Site of the IO: In the study, 78% of the participants received an IV while 22% had an IO placed. The IO was predominantly tibial which may have biased the results. The authors hypothesize that a more proximal route (humeral or sternal) may have made a difference. We think this is unlikely given that there is no high-quality evidence that any ACLS drug for adult OHCA has been shown to make a patient-oriented benefit. Comment on Authors’ Conclusion Compared to SGEM Conclusion: We agree that there is no statistical difference in IV or IO administration of antiarrhythmic medications compared to placebo. A subgroup showed there may (or may not) be a benefit to giving amiodarone IV but that would need to be confirmed. SGEM Bottom Line: We suggest focusing on the treatments that have demonstrated to provide a patient-oriented benefit (high-quality CPR and defibrillation) in adult OHCA rather than those treatments that do not have high-quality evidence to support their use (type of airway, vascular access, vasopressors, or antiarrhythmic drugs).

Date: August 7th, 2021 Dr. Susanne DeMeester Guest Skeptic: Dr. Susanne (Susy) DeMeester is an Emergency Physician practicing at St. Charles Medical Center in Bend, Oregon. She has been very involved with EMRAP's CorePendium as the cardiovascular section editor and has a chapter coming out soon on women and acute coronary syndrome. Dr. DeMeester was on SGEM#222 as part of the SGEMHOP series. She was the lead author of a study looked at whether an emergency department algorithm for atrial fibrillation management decrease the number of patients admitted to hospital. The SGEM Bottom Line: There are clearly patients with primary atrial fibrillation who can be managed safely as outpatients. There are no evidence-based criteria for identifying high-risk patients who require admission, so for now we will have to rely on clinical judgement. This SGEM Xtra episode is the result of some feedback I received from a listener following SGEM#337 episode on the GRACE-1 guidelines for recurrent low-risk chest pain. The person lamented that it would be nice if a cardiac case scenario was of a female patient. This made me review past SGEM episodes which confirmed there has been a gender bias. While there were a half-dozen episodes that did have female patients, they were the minority. So, I felt a good way to address the issue would be to invite an expert like Dr. DeMeester to discuss this gender bias. There is a difference between gender and sex. Despite having different meanings they are often used interchangeably. Gender refers to social constructs while sex refers to biological attributes. This is not the first SGEM episode that has addressed the gender gap in the house of medicine. I had the honour of presenting at the 2019 FeminEM conference called Female Idea Exchange (FIX19). My FIX19 talk was called from Evidence-Based Medicine to Feminist-Based Medicine. It looked at the three pillars of EBM: relevant scientific literature, clinicians, and patients. I realized that each of the three pillars contained biases against women. In the presentation, multiple references were provided to support the claim that a gender gap does exist. The conclusion from the FIX19 talk was that we should be moving from Evidence-Based Medicine (nerdy and male dominated) to Feminist-Based Medicine (recognizing the inequities in the house of medicine) to Gender-Based Medicine (acknowledging the spectrum of gender and sexuality) and ultimately to Humanist- Based Medicine. The SGEM did a regular critical appraisal of a recent publication with Dr. Ester Choo (SGEM#248). It covered the study published in AEM looking at the continuation of gender disparities among academic emergency physicians (Wiler et al AEM 2019). We also did an entire SGEM Xtra episode with Dr. Michelle Cohen on the broader issue of the gender pay gap (SGEM Xtra: Money, Money, Money It’s A Rich Man’s World – In the House of Medicine). This was based on the Canadian Medical Association Journal article focusing on closing the gender pay gap in Canada (Cohen and Kiren 2020). Five questions about gender disparities when it comes to cardiovascular disease. What is the burden of cardiovascular disease in females and is it the same as males? We know females are often excluded from being subjects in medical research. Are female represented proportionally in cardiovascular disease  clinical research? Are there differences between males and females with regards to cardiovascular disease risk factors? Do females who have a cardiovascular event present differently to the emergency department? Have any sex differences been identified in the treatment and outcomes of females with cardiovascular events? Please listen to the SGEM podcast to hear Dr. DeMeester's answers to these five questions. What can be done to address this gender gap? The Lancet gathered a group of international experts to answer this question. The commission published recommendations to reduce the global burden of cardiovascular disease in women by 2030 (Vogel et al). This Includes: Acknowledging the current burden of disease Raising awareness about the differences in presentations and sex-specific and under-recognized risk factors Increasing the number of women included in clinical trials The European Society of Cardiology supported this initiative. They published an article called: Cardiovascular Disease in Women - Reducing the gender gap in prevention, diagnosis and treatment of cardiovascular disease.  The Lancet also created a number of infographics to help with the knowledge translation of these recommendations. The SGEM will be back next episode doing a structured critical appraisal of a recent publication. Trying to cut the knowledge translation window down from over ten years to less than one year using the power of social media. The ultimate goal of the SGEM is for patients get the best care, based on the best evidence. Remember to be skeptical of anything you learn, even if you heard it on the Skeptics’ Guide to Emergency Medicine. Additional Reading: Davies RE, Rier JD. Gender Disparities in CAD: Women and Ischemic Heart Disease. Curr Atheroscler Rep. 2018 Sep 4;20(10):51. doi: 10.1007/s11883-018-0753-7. PMID: 30178384 Mehilli J, Presbitero P. Coronary artery disease and acute coronary syndrome in women. Heart 2020;106:487-492. Greenwood BN, Carnahan S, Huang L. Patient-physician gender concordance and increased mortality among female heart attack patients. Proc Natl Acad Sci U S A. 2018 Aug 21;115(34):8569-8574. doi: 10.1073/pnas.1800097115. Epub 2018 Aug 6. PMID: 30082406; PMCID: PMC6112736 Nguyen PK, Nag D, Wu JC. Sex differences in the diagnostic evaluation of coronary artery disease. J Nucl Cardiol. 2011;18(1):144-152. doi:10.1007/s12350-010-9315-2 Lichtman JH, Leifheit EC, Safdar B, Bao H, Krumholz HM, Lorenze NP, Daneshvar M, Spertus JA, D'Onofrio G. Sex Differences in the Presentation and Perception of Symptoms Among Young Patients With Myocardial Infarction: Evidence from the VIRGO Study (Variation in Recovery: Role of Gender on Outcomes of Young AMI Patients). Circulation. 2018 Feb 20;137(8):781-790. doi: 10.1161/CIRCULATIONAHA.117.031650. PMID: 29459463; PMCID: PMC5822747 Mosca L, Benjamin EJ, Berra K, Bezanson JL, Dolor RJ, Lloyd- Jones DM, et al. Effectiveness-based guidelines for the prevention of cardiovascular disease in women–2011 update: a guideline from the American Heart Association. Circulation. 2011;123:1243–62 Canto JG, Rogers WJ, Goldberg RJ, et al. Association of age and sex with myocardial infarction symptom presentation and in- hospital mortality. JAMA Internal Medicine, American Medical Association, 22 Feb 2012, jamanetwork.com/journals/jama/ fullarticle/1355992 Roger VL, Go AS, Lloyd-Jones DM, et al. Heart disease and stroke statistics—2012 update; a report from the American Heart Association http://Circ.ahajournals.org/Content/125/1/e2.Full, 3 Jan. 2012, circ.ahajournals.org/content/125/1/e2.full Alexander KP, Chen AY, Newby LK, Schwartz JB, Redberg RF, Hochman JS, et al. Sex differences in major bleeding with glyco-protein IIb/IIIa inhibitors: results from the CRUSADE (Can Rapid risk stratification of Unstable angina patients Suppress ADverse outcomes with Early implementation of the ACC/AHA guidelines) initiative. Circulation. 2006;114:1380–7 Regitz-Zagrosek V, Blomstrom LC, Borghi C, et al. ESC guidelines on the management of cardiovascular diseases during pregnancy: the Task Force on the Management of Cardiovascular Diseases during Pregnancy of the European Society of Cardiology (ESC). Eur Heart J. 2011;32:3147–97 Dey S, Flather MD, Devlin G, Brieger D, Gurfinkel EP, Steg PG, et al. Sex-related differences in the presentation, treatment and outcomes among patients with acute coronary syndromes: the Global Registry of Acute Coronary Events. Heart. 2009;95:20–6 Bank IEM, de Hoog VC, de Kleijn DPV, et al. Sex-Based Differences in the Performance of the HEART Score in Patients Presenting to the Emergency Department With Acute Chest Pain. J Am Heart Assoc. 2017;6(6):e005373. Published 2017 Jun 21. doi:10.1161/JAHA.116.005373