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Questions Posed and Answers from the Literature




Critical Appraisal of Literature – Therapy

May 10th, 2010 · Uncategorized

Straus SE, Richardson WS, Glasziou P, Haynes RB.  Evidence-based medicine: how to practice and teach EBM, 3nd ed. Elsevier Churchill Livingston: 2005. pp 115-143.

Kheirandish-Gozal L, Gozal D. Intranasal budesonide treatment for children with mild obstructive sleep apnea syndrome. Pediatrics 2008;122:e149-e155.

Are the results of this single preventive or therapeutic trial valid?

  1. Was the assignment of patients to treatments randomized?
  2. Was the randomization list concealed?
  3. Was follow-up of patients sufficiently long and complete?
  4. Were all patients analyzed in the groups to which they were randomized?
  5. Were patients, clinicians, and study personnel kept “blind” to treatment?
  6. Were the groups treated equally, apart from the experimental treatment?
  7. Were the groups similar at the start of the trial apart from the experimental therapy?

Are the valid results of this randomized trial important?

  1. What is the magnitude of the treatment effect?
  2. How precise is the estimate of the treatment effect?

SAMPLE CALCULATIONS

Occurrence of diabetic neuropathy at 5 years among insulin-dependent diabetics in the DCCT trial

Relative risk reduction (RRR)

Absolute risk reduction (ARR)

Number needed to treat (NNT)

Usual insulin regimen control event rate (CER)

Intensive insulin regimen experimental event rate (EER)

CER – EER

CER

CER – EER

1/ARR

9.6% 2.8%

9.6% – 2.8%

9.6%

=71%

9.6% – 2.8%

=6.8%

1/6.8%

=15 patients

95% CIa

4.4% to 9.2%

11 to 23

a95% confidence interval (CI) on an NNT

=1/(limits on the CI of its ARR)

YOUR CALCULATIONS

Relative risk reduction (RRR)

Absolute risk reduction (ARR)

Number needed to treat (NNT)

CER

EER

CER – EER

CER

CER – EER

1/ARR

95% CI


Can you apply this valid, important evidence about theapy in caring for your patient?

  1. Do these results apply to our patient?
  2. Is our patient so different from those in the study that its results cannot apply?
  3. Is the treatment feasible in our setting?
  4. What are our patient’s potential benefits and harms from the therapy?
Method I: f Risk of the outcome in our patient, relative to patients in the trial.

Expressed as a decimal:______

NNT/f=______/______=______

(NNT for patients like ours)

Method II: 1/(PEER´RRR) Our patient’s expected event rate if they received the control treatment (PEER)

=______

1/(PEER´RRR)=1/________=______

(NNT for patients like ours)

  1. Are our patient’s values and preference satisfied by the regimen and its consequences?
  2. Do we and our patient have a clear assessment of their values and preferences?
  3. Are they met by this regimen and its consequences?

Additional notes:

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May 2010

May 4th, 2010 · Uncategorized

1. Bolger WE, Brown CL, Church CA, et al. Safety and outcomes of balloon catheter sinusotomy: a multicenter 24-week analysis in 115 patients. Otolaryngol Head Neck Surg. 2007;137(1):10-20.

Comment: Rice DH. Balloon catheter sinusotomy. Otolaryngol Head Neck Surg. 2008;138(1):126; author reply 126-7. 10.1016/j.otohns.2007.10.001.

2. Weiss RL, Church CA, Kuhn FA, Levine HL, Sillers MJ, Vaughan WC. Long-term outcome analysis of balloon catheter sinusotomy: two-year follow-up. Otolaryngol Head Neck Surg. 2008;139(3 Suppl 3):S38-46.

3. Smith TL, Litvack JR, Hwang PH, et al. Determinants of outcomes of sinus surgery: a multi-institutional prospective cohort study. Otolaryngol Head Neck Surg. 2010;142(1):55-63.

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April 2010

May 4th, 2010 · Uncategorized

1. Leaute-Labreze, C., Dumas de la Roque, E., Hubiche, T., Boralevi, F., Thambo, J. B., & Taieb, A. (2008). Propranolol for severe hemangiomas of infancy. The New England Journal of Medicine, 358(24), 2649-2651. doi:10.1056/NEJMc0708819

Supplementary Index

Figure 1

Related articles of interest…

Sans, V., Dumas de la Roque, E., Berge, J., Grenier, N., Boralevi, F., Mazereeuw-Hautier, J., Lipsker, D., Dupuis, E., Ezzedine, K., Vergnes, P., Taieb, A., & Leaute-Labreze, C. (2009). Propranolol for severe infantile hemangiomas: Follow-up report. Pediatrics, doi:10.1542/peds.2008-3458

Truong, M. T., Chang, K. W., Berk, D. R., Heerema-McKenney, A., & Bruckner, A. L. (2010). Propranolol for the treatment of a life-threatening subglottic and mediastinal infantile hemangioma. The Journal of Pediatrics, 156(2), 335-338. doi:10.1016/j.jpeds.2009.10.010

2. Nadeau, D. P., Rich, J. N., & Brietzke, S. E. (2010). Informed consent in pediatric surgery: Do parents understand the risks? Archives of Otolaryngology–Head & Neck Surgery, 136(3), 265-269. doi:10.1001/archoto.2010.5

3. Zevallos, J. P., Vrabec, J. T., Williamson, R. A., Giannoni, C., Larrier, D., Sulek, M., Friedman, E. M., & Oghalai, J. S. (2009). Advanced pediatric mastoiditis with and without intracranial complications. The Laryngoscope, 119(8), 1610-1615. doi:10.1002/lary.20259

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Otolaryngology Journal Club has a new home

May 4th, 2010 · Uncategorized

Check out the new Otolaryngology Guide to Information (OGI) for journal club articles, related articles, and much more information to support Otolaryngology clinical and research work.

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Face Transplants Available to Wounded Veterans

January 12th, 2010 · January 2009

Re posted from The Plastic Surgery Channel

Face transplant surgery will be available to wounded war veterans, thanks to a new multimillion dollar contract awarded by the U.S. Department of Defense.  Currently, less than ten face transplants have been performed worldwide, but eight more are expected to be performed in the next 18 months.

Wounded war veterans will be able to get face transplants if needed, thanks to a new multimillion dollar contract awarded by the U.S. Department of Defense.

The face transplant is a rare procedure; less than ten of them have ever been performed. But doctors at Brigham and Women’s Hospital in Boston may perform eight more over the next 18 months after receiving $3.4 million from the government. Each operation costs as much as $300,000, and insurance won’t cover it.

The patients are expected to be war veterans disfigured after injuries sustained by improvised explosive devices in Iraq or Afghanistan. However, a patient only qualifies for a face transplant, if he’s missing at least 25 percent of his face and can’t be treated through any other surgical methods.

The Boston hospital performed one face transplant in April, which was only the second one ever performed in America. But right now, sources say, as many as 200 veterans may have injuries that qualify them for this operation.

RELATED STORIES:

Veterans Offered Low-Cost Plastic Surgery (VIDEO)

Performing Cosmetic Surgery Prepares Military Docs to Aid Wounded Soldiers (VIDEO)

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January Journal Club Articles

December 28th, 2009 · January 2009

Alam, D. S., Papay, F., Djohan, R., Bernard, S., Lohman, R., Gordon, C. R., Hendrickson, M., & Siemionow, M. (2009). The technical and anatomical aspects of the world’s first near-total human face and maxilla transplant. Archives of Facial Plastic Surgery : Official Publication for the American Academy of Facial Plastic and Reconstructive Surgery, Inc.and the International Federation of Facial Plastic Surgery Societies, 11(6), 369-377. doi:10.1001/archfacial.2009.80

This article has  Commentary from Dr. Larrabee and Dr. Hilger that raise  the questions…

  • What is different about this transplant?
  • Why was it performed when traditional reconstructive techniques   have provided acceptable results for decades?

Kridel, R. W., Ashoori, F., Liu, E. S., & Hart, C. G. (2009). Long-term use and follow-up of irradiated homologous costal cartilage grafts in the nose. Archives of Facial Plastic Surgery : Official Publication for the American Academy of Facial Plastic and Reconstructive Surgery, Inc.and the International Federation of Facial Plastic Surgery Societies, 11(6), 378-394. doi:10.1001/archfacial.2009.91

This article has a Supplement.

This article also has a Commentary from Dr. Larrabee, …—epitomizes the meticulous clinical observation that we all should strive to achieve in our practices.”

* It should be noted that Dr. Larrabee is currently serving as Editor for the Archives of Facial Plastic Surgery.

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December Journal Club Articles

December 8th, 2009 · December 2009

1. Safety of high-dose corticosteroids for the treatment of autoimmune inner ear disease. Alexander TH, Weisman MH, Derebery JM, et al. Otol Neurotol. 2009;30(4):443-448.

2. Combination therapy (intratympanic dexamethasone + high-dose prednisone taper) for the treatment of idiopathic sudden sensorineural hearing loss. Battaglia A, Burchette R, Cueva R. Otol Neurotol. 2008;29(4):453-460.

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