Academic Research Curriculum (ARC) #7 – Attending Guide

Gastroenterology

Clinical Scenario:

You are on night float, and last night you admitted Mr. Mel E. Na to the general medicine service. He is a 65yo man with a history of HTN, HL, and chronic back pain on NSAIDs who presented with 3 days of dark tarry stools. Though he was hemodynamically stable after fluid resuscitation, you noted a 4g drop in his hemoglobin from baseline. GI completed the EGD showing an actively bleeding ulcer, which they cauterized. He is ordered a PPI bolus and continuous infusion for a planned 72 hours based upon current guidelines.

Excerpt from: Laine L, Jensen DM. Management of patients with ulcer bleeding. ACG Practice Guidelines. Am J Gastroenterol 2012;107:345-60.

Later that evening, pharmacy calls and tells you that pantoprazole is on ultimate mega-back order and is now $60,000 per vial.* Can we use an oral PPI or bolus dosing?

*Literary hyperbole is an artistic liberty added here for emphasis

Sachar H, Vaidya K, Laine L. Intermittent vs continuous proton pump inhibitor therapy for high-risk bleeding ulcers: a systematic review and meta-analysis. JAMA Intern Med 2014;174:1755-62.

Before we delve into the design and stats and findings, it is important to define a few terms clearly.

  1. What is a systematic review? How is this different from a non-systematic or narrative review?
  1. What is a meta-analysis?
  1. What was the primary objective of this study and how did they define it? Is this appropriate?

When evaluating any piece of medical literature, it is important to establish that the methods are sound and the analysis is appropriate. These next questions will review how to approach credibility of a systematic review.

  1. Did the review explicitly address a sensible clinical question? Is the inclusion too narrow/broad?
  1. In RCTs, methods detail the study design with inclusion and exclusion criteria for patients which make up the data of the study. How do systematic reviews approach detailing their methods?
  1. Was the risk of bias of the primary studies assessed?
  1. What is the purpose of a funnel plot? (Figure 2) How do you read this?
  1. What is Egger's test?
  1. Evaluate Figure 3. How do you interpret a Forrest plot?
  1. How do you interpret the heterogeneity values in the Forrest plot? What statistical tests do you see presented here?
  1. What was the overall effect? Was non-inferiority achieved?
  1. What are some of the strengths and limitations of this study?
  1. How would apply this to Mr. Na? How do you anticipate this changing your clinical practice? Should we switch to intermittent PO dosing and never use drips?