In this episode we:
1. Learn the importance of treatment studies (Randomized Controlled Trials) in EBM
2. Understand and interpret methods and results of treatment based studies
3. Become familiar with critically appraising treatment based studies
Part 1 examines the trial validity
Part 2 covers the results
Hosts:
- Dylan Collins
- Levi Johnston
- Dakoda Herman
- Jayneel Limbachia
- Jake Domm
Paper:
- Warren, Jaimee, et al. “Antacid Monotherapy Is More Effective in Relieving Epigastric Pain Than in Combination With Lidocaine: A Randomized Double‐blind Clinical Trial.” Academic Emergency Medicine 27.9 (2020): 905-909. https://onlinelibrary.wiley.com/doi/epdf/10.1111/acem.14069
EBM Checklist for therapy studies (University of Oxford):
Episode takeaway
- Randomized Controlled Trials are considered gold standard in terms of evidence since the randomization process controls for both known and unknown confounding variables
- Understanding how to quickly and efficiently appraise studies by assessing its methods is an important skill that can help you assess its utility to your practice and whether the authors adequately answered the question
- Use a validated critical appraisal tool. We used the CEBM tool, but there are others. The GATE from by Rod Jackson is another great method to learn. Know that sometimes people use publishing guidelines as critical appraisal tools, like the CONSORT for RCTs, but these are just work arounds.
- Be skeptical and curious. If there is a published protocol, check it. Look at who funded the study. Read the COI and method to mitigate bias.
Clinical Pearl
What are common/important causes of epigastric pain?
- Acute myocardial infarction:
- Remember to consider a patient’s cardiac risk factors
- May be associated with exertion or shortness of breath
- Acute pancreatitis:
- Acute-onset, persistent upper abdominal pain radiating to the back.
- Chronic pancreatitis:
- Epigastric pain radiating to the back.
- Associated with pancreatic insufficiency
- Peptic ulcer disease:
- Epigastric pain or discomfort is the most prominent symptom
- Discomfort can lateralize to one side of the abdomen
- Gastroesophageal reflux disease:
- Associated with heartburn, regurgitation, and dysphagia.
- Gastritis:
- Abdominal discomfort/pain, heartburn, nausea, vomiting, and hematemesis.
- Variety of etiologies including alcohol and nonsteroidal antiinflammatory drugs (NSAIDs).
- Gastroparesis:
- Nausea, vomiting, abdominal pain, early satiety, postprandial fullness, and bloating.
- Most cases or idiopathic, diabetic, or postsurgical
- Functional dyspepsia:
- The presence of one or more of the following in the absence of evidence for structural disease:
- Postprandial fullness
- Early satiation
- Epigastric pain
- Epigastric burning
- The presence of one or more of the following in the absence of evidence for structural disease:
Does symptomatic improvement with a gastrointestinal cocktail help rule out myocardial ischemia?
- Unfortunately, symptomatic improvement with a “GI cocktail” cannot reliably rule out ischemic chest pain.
Does symptomatic improvement with nitroglycerin support the diagnosis of ischemic chest pain?
- Again, unfortunately symptomatic improvement with nitroglycerin is nonspecific for ischemic chest pain, as other causes, such as esophageal spasm, can also improve with this intervention.
Dyspepsia Red Flags:
- Age > 60 years with new/persistent symptoms
- GI Bleeding
- Iron-deficiency anemia
- Progessive dypshagia
- Persistent vomiting
- Unintended weight loss
- Personal history of peptic ulcer disease
- Family history of upper GI cancer
Resources:
- The argument against statistical significance – Amrhein et al. 2019, Nature (https://www.nature.com/articles/d41586-019-00857-9)
Produced by Dr. Kevin J Dong
Jakob Domm
Jake is a 3rd year medical student at Dalhousie Medical School. He has interests in EM and research, completing his MSc. at Guelph University in pathobiology. Outside of medicine, Jake enjoys crossfitting with his wife and hiking with their dog.