WikEM - User contributions [en]

EBQ:Thrombolysis in Pulmonary Embolism Metanalysis

2014-09-25T03:29:18Z

Patarchambault:

{{JC info
| title= Thrombolysis for Pulmonary Embolism and Risk of All-Cause Mortality, Major Bleeding, and Intracranial Hemorrhage
| abbreviation=
| expansion=
| published= 2014 Jun 18
| author= Chatterjee S, Chakraborty A, Weinberg I, Kadakia M, Wilensky RL, Sardar P, Kumbhani DJ, Mukherjee D, Jaff MR, Giri J.
| journal= JAMA
| year= 2014
| volume= 311
| issue=23
| pages= 2414-21
| pmid= [http://www.ncbi.nlm.nih.gov/pubmed/24938564 24938564]
| fulltexturl=
| pdfurl=
}}
==Clinical Question==
What are the mortality benefits and bleeding risks associated with thrombolytic therapy compared with anticoagulation in acute PE?

==Conclusion==
Among patients with pulmonary embolism, including those who were hemodynamically stable with right ventricular dysfunction, thrombolytic therapy was associated with lower rates of all-cause mortality and increased risks of major bleeding and ICH

==Major Points==
Comment from Beckman in [http://www.ncbi.nlm.nih.gov/pubmed/24938561 editorial] (JAMA): "The accrual of 2000 patients over 45 years for a problem associated with 200 000 hospitalizations and 30 000 deaths per year suggests need for a large definitive trial, perhaps stratifying patients by age, using lower doses of thrombolytic agents, or applying a catheter-based strategy to reduce the potentially lethal bleeding risk. In the meantime, thrombolytic therapy should be individualized based on clinical presentation, comorbid conditions, and patient and physician risk tolerance. (...) Additional clinical trials are needed to guide optimal use of thrombolytic therapy in patients with PE."
==Study Design==
Meta-analysis of all RCTs on thrombolysis in PE, risk of bias was assessed for the domains suggested by the Cochrane Handbook of Systematic Reviews
Studies were divided in groups depending on the risk of mortality associated with different presentations of PE: (1) low-risk (hemodynamically stable without objective evidence of RV dysfunction), (2) intermediate-risk (hemodynamically stable with objective evidence of RV dysfunction), high-risk (hemodynamically unstable and/or documented systolic blood pressure <90 mm Hg), or unclassifiable (patient information not adequate to determine risk level)

==Population==
Patients with PE
===Patient Demographics===

===Inclusion Criteria===

===Exclusion Criteria===

==Interventions==
Thrombolytic therapy compared to low-molecular-weight heparin (LMWH), vitamin K antagonist, fondaparinux, or unfractionated heparin
==Outcomes==
Primary: all-cause mortality and major bleeding
Secondary: risk of recurrent embolism and intracranial hemorrhage (ICH).
===Primary Outcome===
1- mortality thrombolysis vs. anticoagulants (OR, 0.53; 95%CI, 0.32-0.88; 2.17% [23/1061] vs 3.89% [41/1054];NNT=59
===Secondary Outcomes===
1- major bleeding (OR, 2.73; 95%CI, 1.91-3.91; 9.24% [98/1061] vs 3.42%[36/1054]; NNH=18
2- ICH (OR, 4.63; 95%CI, 1.78-12.04; 1.46%[15/1024] vs 0.19% [2/1019]; NNH=78
3- Major bleeding was not significantly increased in pts < 65 years (OR, 1.25; 95%CI, 0.50-3.14)
4- Thrombolysis was associated with a lower risk of recurrent PE (OR, 0.40; 95%CI, 0.22-0.74; 1.17%[12/1024] vs 3.04%[31/1019];NNT=54

===Subgroup analysis===
1- Intermediate-risk PE: thrombolysis was associated with lower mortality (OR, 0.48; 95%CI, 0.25-0.92) and more major bleeding events (OR, 3.19; 95%CI, 2.07-4.92).

==Criticisms & Further Discussion==
1- There are still very few patients (n=2115) included in RCT assessing impact of thrombolysis in PE to conclude with assurance about benefit or harm. Need exists for adequately powered study.
2- There is only one study (ULTIMA) having analyzed the effect of catheter-delivered thrombolysis via a pulmonary artery catheter and results of this review should only be applied to systemic thrombolysis.

==External Links==

==Funding==

==Sources==
<references/>

[[Category:EBQ]]

EBQ:Thrombolysis in Pulmonary Embolism Metanalysis

2014-09-25T03:26:39Z

Patarchambault:

{{JC info
| title= Thrombolysis for Pulmonary Embolism and Risk of All-Cause Mortality, Major Bleeding, and Intracranial Hemorrhage
| abbreviation=
| expansion=
| published= 2014 Jun 18
| author= Chatterjee S, Chakraborty A, Weinberg I, Kadakia M, Wilensky RL, Sardar P, Kumbhani DJ, Mukherjee D, Jaff MR, Giri J.
| journal= JAMA
| year= 2014
| volume= 311
| issue=23
| pages= 2414-21
| pmid= [http://www.ncbi.nlm.nih.gov/pubmed/24938564 24938564]
| fulltexturl=
| pdfurl=
}}
==Clinical Question==
What are the mortality benefits and bleeding risks associated with thrombolytic therapy compared with anticoagulation in acute pulmonary embolism?

==Conclusion==
Among patients with pulmonary embolism, including those who were hemodynamically stable with right ventricular dysfunction, thrombolytic therapy was associated with lower rates of all-cause mortality and increased risks of major bleeding and ICH

==Major Points==
Comment from Beckman in [http://www.ncbi.nlm.nih.gov/pubmed/24938561 editorial] (JAMA): "The accrual of 2000 patients over 45 years for a problem associated with 200 000 hospitalizations and 30 000 deaths per year suggests need for a large definitive trial, perhaps stratifying patients by age, using lower doses of thrombolytic agents, or applying a catheter-based strategy to reduce the potentially lethal bleeding risk. In the meantime, thrombolytic therapy should be individualized based on clinical presentation, comorbid conditions, and patient and physician risk tolerance. (...) Additional clinical trials are needed to guide optimal use of thrombolytic therapy in patients with PE."
==Study Design==
Meta-analysis of all RCTs on thrombolysis in PE, risk of bias was assessed for the domains suggested by the Cochrane Handbook of Systematic Reviews
Studies were divided in groups depending on the risk of mortality associated with different presentations of PE: (1) low-risk (hemodynamically stable without objective evidence of RV dysfunction), (2) intermediate-risk (hemodynamically stable with objective evidence of RV dysfunction), high-risk (hemodynamically unstable and/or documented systolic blood pressure <90 mm Hg), or unclassifiable (patient information not adequate to determine risk level)

==Population==
Patients with PE
===Patient Demographics===

===Inclusion Criteria===

===Exclusion Criteria===

==Interventions==
Thrombolytic therapy compared to low-molecular-weight heparin (LMWH), vitamin K antagonist, fondaparinux, or unfractionated heparin
==Outcomes==
Primary: all-cause mortality and major bleeding
Secondary: risk of recurrent embolism and intracranial hemorrhage (ICH).
===Primary Outcome===
1- mortality thrombolysis vs. anticoagulants (OR, 0.53; 95%CI, 0.32-0.88; 2.17% [23/1061] vs 3.89% [41/1054];NNT=59
===Secondary Outcomes===
1- major bleeding (OR, 2.73; 95%CI, 1.91-3.91; 9.24% [98/1061] vs 3.42%[36/1054]; NNH=18
2- ICH (OR, 4.63; 95%CI, 1.78-12.04; 1.46%[15/1024] vs 0.19% [2/1019]; NNH=78
3- Major bleeding was not significantly increased in pts < 65 years (OR, 1.25; 95%CI, 0.50-3.14)
4- Thrombolysis was associated with a lower risk of recurrent PE (OR, 0.40; 95%CI, 0.22-0.74; 1.17%[12/1024] vs 3.04%[31/1019];NNT=54

===Subgroup analysis===
1- Intermediate-risk PE: thrombolysis was associated with lower mortality (OR, 0.48; 95%CI, 0.25-0.92) and more major bleeding events (OR, 3.19; 95%CI, 2.07-4.92).

==Criticisms & Further Discussion==
1- There are still very few patients (n=2115) included in RCT assessing impact of thrombolysis in PE to conclude with assurance about benefit or harm. Need exists for adequately powered study.
2- There is only one study (ULTIMA) having analyzed the effect of catheter-delivered thrombolysis via a pulmonary artery catheter and results of this review should only be applied to systemic thrombolysis.

==External Links==

==Funding==

==Sources==
<references/>

[[Category:EBQ]]

EBQ:Thrombolysis in Pulmonary Embolism Metanalysis

2014-09-25T03:25:05Z

Patarchambault: edit of title

{{JC info
| title= Thrombolysis for Pulmonary Embolism and Risk of All-Cause Mortality, Major Bleeding, and Intracranial Hemorrhage
| abbreviation=
| expansion=
| published= 2014 Jun 18
| author= Chatterjee S, Chakraborty A, Weinberg I, Kadakia M, Wilensky RL, Sardar P, Kumbhani DJ, Mukherjee D, Jaff MR, Giri J.
| journal= JAMA
| year= 2014
| volume= 311
| issue=23
| pages= 2414-21
| pmid= [http://www.ncbi.nlm.nih.gov/pubmed/24938564 24938564]
| fulltexturl=
| pdfurl=
}}
==Clinical Question==
What are the mortality benefits and bleeding risks associated with thrombolytic therapy compared with anticoagulation in acute pulmonary embolism?

==Conclusion==
Among patients with pulmonary embolism, including those who were hemodynamically stable with right ventricular dysfunction, thrombolytic therapy was associated with lower rates of all-cause mortality and increased risks of major bleeding and ICH

==Major Points==
Comment from Beckman in [http://www.ncbi.nlm.nih.gov/pubmed/24938561 editorial] (JAMA): "The accrual of 2000 patients over 45 years for a problem associated with 200 000 hospitalizations and 30 000 deaths per year suggests need for a large definitive trial, perhaps stratifying patients by age, using lower doses of thrombolytic agents, or applying a catheter-based strategy to reduce the potentially lethal bleeding risk. In the meantime, thrombolytic therapy should be individualized based on clinical presentation, comorbid conditions, and patient and physician risk tolerance. (...) Additional clinical trials are needed to guide optimal use of thrombolytic therapy in patients with PE."
==Study Design==
Meta-analysis of all RCTs on thrombolysis in PE, risk of bias was assessed for the domains suggested by the Cochrane Handbook of Systematic Reviews
Studies were divided in groups depending on the risk of mortality associated with different presentations of PE: (1) low-risk (hemodynamically stable without objective evidence of RV dysfunction), (2) intermediate-risk (hemodynamically stable with objective evidence of RV dysfunction), high-risk (hemodynamically unstable and/or documented systolic blood pressure <90 mm Hg), or unclassifiable (patient information not adequate to determine risk level)

==Population==
Patients with PE
===Patient Demographics===

===Inclusion Criteria===

===Exclusion Criteria===

==Interventions==
Thrombolytic therapy compared to low-molecular-weight heparin (LMWH), vitamin K antagonist, fondaparinux, or unfractionated heparin
==Outcomes==
Primary: all-cause mortality and major bleeding
Secondary: risk of recurrent embolism and intracranial hemorrhage (ICH).
===Primary Outcome===
1- mortality thrombolysis vs. anticoagulants (OR, 0.53; 95%CI, 0.32-0.88; 2.17% [23/1061] vs 3.89% [41/1054];NNT=59
===Secondary Outcomes===
1- major bleeding (OR, 2.73; 95%CI, 1.91-3.91; 9.24% [98/1061] vs 3.42%[36/1054]; NNH=18
2- ICH (OR, 4.63; 95%CI, 1.78-12.04; 1.46%[15/1024] vs 0.19% [2/1019]; NNH=78
3- Major bleeding was not significantly increased in pts < 65 years (OR, 1.25; 95%CI, 0.50-3.14)
4- Thrombolysis was associated with a lower risk of recurrent PE (OR, 0.40; 95%CI, 0.22-0.74; 1.17%[12/1024] vs 3.04%[31/1019];NNT=54

===Subgroup analysis===
1- Intermediate-risk PE: thrombolysis was associated with lower mortality (OR, 0.48; 95%CI, 0.25-0.92) and more major bleeding events (OR, 3.19; 95%CI, 2.07-4.92).

==Criticisms & Further Discussion==
1- There are still very few patients (n=2115) included in RCT assessing impact of thrombolysis in PE to conclude with assurance about benefit or harm. Need exists for adequately powered study.
2- There is only one study (ULTIMA) having analyzed the effect of catheter-delivered thrombolysis via a pulmonary artery catheter and results of this review should only be applied to systemic thrombolysis.

==External Links==

==Funding==

==Sources==
<references/>

[[Category:EBQ]]

EBQ:Thrombolysis in Pulmonary Embolism Metanalysis

2014-09-25T03:22:54Z

Patarchambault: Summary of the Meta-analysis on thrombolysis in PE published in JAMA 2014

{{JC info
| title= Thrombolysis for Pulmonary Embolism and Risk of All-Cause Mortality, Major Bleeding, and Intracranial Hemorrhage
| abbreviation=
| expansion=
| published= 2014 Jun 18
| author= Chatterjee S, Chakraborty A, Weinberg I, Kadakia M, Wilensky RL, Sardar P, Kumbhani DJ, Mukherjee D, Jaff MR, Giri J.
| journal= JAMA
| year= 2014
| volume= 311
| issue=23
| pages= 2414-21
| pmid= [http://www.ncbi.nlm.nih.gov/pubmed/24938564 24938564]
| fulltexturl=
| pdfurl=
}}
==Clinical Question==
What are the mortality benefits and bleeding risks associated with thrombolytic therapy compared with anticoagulation in acute pulmonary embolism, including the subset of hemodynamically stable patients with right ventricular dysfunction (intermediate-risk pulmonary embolism)?

==Conclusion==
Among patients with pulmonary embolism, including those who were hemodynamically stable with right ventricular dysfunction, thrombolytic therapy was associated with lower rates of all-cause mortality and increased risks of major bleeding and ICH

==Major Points==
Comment from Beckman in [http://www.ncbi.nlm.nih.gov/pubmed/24938561 editorial] (JAMA): "The accrual of 2000 patients over 45 years for a problem associated with 200 000 hospitalizations and 30 000 deaths per year suggests need for a large definitive trial, perhaps stratifying patients by age, using lower doses of thrombolytic agents, or applying a catheter-based strategy to reduce the potentially lethal bleeding risk. In the meantime, thrombolytic therapy should be individualized based on clinical presentation, comorbid conditions, and patient and physician risk tolerance. (...) Additional clinical trials are needed to guide optimal use of thrombolytic therapy in patients with PE."
==Study Design==
Meta-analysis of all RCTs on thrombolysis in PE, risk of bias was assessed for the domains suggested by the Cochrane Handbook of Systematic Reviews
Studies were divided in groups depending on the risk of mortality associated with different presentations of PE: (1) low-risk (hemodynamically stable without objective evidence of RV dysfunction), (2) intermediate-risk (hemodynamically stable with objective evidence of RV dysfunction), high-risk (hemodynamically unstable and/or documented systolic blood pressure <90 mm Hg), or unclassifiable (patient information not adequate to determine risk level)

==Population==
Patients with PE
===Patient Demographics===

===Inclusion Criteria===

===Exclusion Criteria===

==Interventions==
Thrombolytic therapy compared to low-molecular-weight heparin (LMWH), vitamin K antagonist, fondaparinux, or unfractionated heparin
==Outcomes==
Primary: all-cause mortality and major bleeding
Secondary: risk of recurrent embolism and intracranial hemorrhage (ICH).
===Primary Outcome===
1- mortality thrombolysis vs. anticoagulants (OR, 0.53; 95%CI, 0.32-0.88; 2.17% [23/1061] vs 3.89% [41/1054];NNT=59
===Secondary Outcomes===
1- major bleeding (OR, 2.73; 95%CI, 1.91-3.91; 9.24% [98/1061] vs 3.42%[36/1054]; NNH=18
2- ICH (OR, 4.63; 95%CI, 1.78-12.04; 1.46%[15/1024] vs 0.19% [2/1019]; NNH=78
3- Major bleeding was not significantly increased in pts < 65 years (OR, 1.25; 95%CI, 0.50-3.14)
4- Thrombolysis was associated with a lower risk of recurrent PE (OR, 0.40; 95%CI, 0.22-0.74; 1.17%[12/1024] vs 3.04%[31/1019];NNT=54

===Subgroup analysis===
1- Intermediate-risk PE: thrombolysis was associated with lower mortality (OR, 0.48; 95%CI, 0.25-0.92) and more major bleeding events (OR, 3.19; 95%CI, 2.07-4.92).

==Criticisms & Further Discussion==
1- There are still very few patients (n=2115) included in RCT assessing impact of thrombolysis in PE to conclude with assurance about benefit or harm. Need exists for adequately powered study.
2- There is only one study (ULTIMA) having analyzed the effect of catheter-delivered thrombolysis via a pulmonary artery catheter and results of this review should only be applied to systemic thrombolysis.

==External Links==

==Funding==

==Sources==
<references/>

[[Category:EBQ]]

EBQ:High Priority Articles

2014-09-25T03:09:59Z

Patarchambault: added an important article to the list of high priority articles to know

==Background==
As part of the [[WikEM:Journal Club (Main)|WikEM Journal Club]], this page is a list of high priority articles. If you feel there is an article missing from the list feel free to add it and begin contributing.

==High Priority Articles for Review==
*2014 [[Thrombolysis in Pulmonary Embolism Metanalysis]] [http://www.ncbi.nlm.nih.gov/pubmed/24938564 PMID:24938564] Thrombolysis for Pulmonary Embolism and Risk of All-Cause Mortality, Major Bleeding, and Intracranial Hemorrhage
*2013 [[Surviving sepsis 2012]] International guidelines for management of severe sepsis and septic shock
*2013 [[Effect of video laryngoscopy on trauma patient survival]]: a randomized controlled trial PMID 23823612
*2013 [[OHCA Prehospital Airway Managment]] PMID 23321764
*2013 [[Transfusion strategies for acute upper gastrointestinal bleeding]] PMID 23281973
*2012 [[Catheter related infections]] The risk of catheter-related bloodstream infection with femoral venous catheters as compared to subclavian and internal jugular venous catheters: a systematic review of the literature and meta-analysis
*2012 [[IST-3]] PMID 22632908
*2010 [[Nasogastric aspiration and lavage in emergency department patients with hematochezia or melena without hematemesis]] Nasogastric aspiration and lavage in emergency department patients with hematochezia or melena without hematemesis.
*2010 [[Lactate clearance vs central venous oxygen saturation]] Lactate clearance vs central venous oxygen saturation as goals of early sepsis therapy: a randomized clinical trial
*2010 [[Perry Subarachnoid Haemorrhage Study]] High risk clinical characteristics for subarachnoid haemorrhage
*2009 [[RE-LY]] Dabigatran versus warfarin in patients with atrial fibrillation PMID 19717844
*2009 [[Validation of a prediction rule for the identification of children with intra-abdominal injuries after blunt torso trauma]]
*2008 [[ECASS III]] Thrombolysis with alteplase 3 to 4.5 hours after acute ischemic stroke
*2007 [[Omeprazole in Bleeding Peptic Ulcers]] Effect of Intravenous Omeprazole on Recurrent Bleeding after Endoscopic Treatment of Bleeding Peptic Ulcer
*2007 [[Validation and refinement of scores to predict very early stroke risk after transient ischaemic attack]]
*2006 [[Single Dose Dexamethasone in Asthma]] Single-dose oral dexamethasone in the emergency management of children with exacerbations of mild to moderate asthma]]
*2006 [[A national evaluation of the effect of trauma-center care on mortality]]
*2006 [[High Dose Steroids in Cord Injury]] Effects of the Second National Acute Spinal Cord Injury Study of high-dose methylprednisolone therapy on acute cervical spinal cord injury-results in spinal injuries center
*2006 [[Incidence and predictors of difficult and impossible mask ventilation]]Incidence and predictors of difficult and impossible mask ventilation
*2006 [[San Francisco Syncope Rule]] Prospective validation of the San Francisco Syncope Rule to predict patients with serious outcomes
*2005 [[End-Tidal CO2 Monitoring]] Does End-tidal Carbon Dioxide Monitoring Detect Respiratory Events Prior to Current Sedation Monitoring Practices?
*2004 [[Vasopressin v Epi in OHCA]] A comparison of vasopressin and epinephrine for out-of-hospital cardiopulmonary resuscitation
*2004 [[LRINEC Score]] The LRINEC (Laboratory Risk Indicator for Necrotizing Fasciitis) score: a tool for distinguishing necrotizing fasciitis from other soft tissue infections
*2003 [[A Comparison of Coronary Angioplasty with Fibrinolytic Therapy in Acute Myocardial Infarction]] A Comparison of Coronary Angioplasty with Fibrinolytic Therapy in Acute Myocardial Infarction
*2002 [[Hematuria in Renal Colic]] Utility of hematuria testing in patients with suspected renal colic: correlation with unenhanced helical CT results
*2002 [[EBQ:De Gans - Steroids for Bacterial Meningitis]] Dexamethasone in Adults with Bacterial Meningitis
*2002 [[AFFIRM]] A Comparison of Rate Control and Rhythm Control in Patients with Atrial Fibrillation
*2002 [[HACA]] Mild Therapeutic Hypothermia to Improve the Neurologic Outcome After Cardiac Arrest
*2001 [[Antibiotic prophylaxis for mammalian bites]] Antibiotic prophylaxis for mammalian bites
*2001 [[Wells PE Rule Out]] Excluding Pulmonary Embolism at the Bedside without Diagnostic Imaging: Management of Patients with Suspected Pulmonary Embolism Presenting to the Emergency Department by Using a Simple Clinical Model and D-Dimer
*2000 [[Indications for computed tomography in patients with minor head injury]]
*2000 [[EBQ:ARDSnet]] Ventilation with Lower Tidal Volumes as Compared with Traditional Tidal Volumes for Acute Lung Injury and the Acute Respiratory Distress Syndrome
*1998 [[Worst headache and subarachnoid hemorrhage]]Worst headache and subarachnoid hemorrhage: prospective, modern computed tomography and spinal fluid analysis
*1998 [[Effective ED Thoracotomy Usage]] Critical analysis of two decades of experience with postinjury emergency department thoracotomy in a regional trauma cente
*1998 [[NEXUS]] Selective cervical spine radiography in blunt trauma: methodology of the National Emergency X-Radiography Utilization Study (NEXUS)
*1997 [[48hr Cardioversion for Afib]] Risk for clinical thromboembolism associated with conversion to sinus rhythm in patients with atrial fibrillation lasting less than 48 hours
*1996 [[EBQ: Sgarbossa Criteria]] Electrocardiographic Diagnosis of Evolving Acute Myocardial Infarction in the Presence of Left Bundle-Branch Block
*1995 [[NIPPV in COPD]] Noninvasive Ventilation for Acute Exacerbations of Chronic Obstructive Pulmonary Disease
*1995 [[NINDS]] Tissue plasminogen activator for acute ischemic stroke. The National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group
*1995 [[Quantitative sensitivity of ultrasound in detecting free intraperitoneal fluid]]
*1994 [[Delayed Fluid Resuscitation in Trauma]] Immediate versus delayed fluid resuscitation for hypotensive patients with penetrating torso injuries
*1993 [[Ottawa Ankle Rule]] Decision rules for the use of radiography in acute ankle injuries. Refinement and prospective validation

==See Also==
[[WikEM:Journal Club (Main)]]

[[Category:EBQ]]