Does “Not Different” Equal “The Same”?
Article Outline
Discussion Points
SEE RELATED ARTICLE, P. 283.
What is already known on this topic
With the increasing prevalence of methicillin-resistant Staphylococcus aureus, there is concern that incision and drainage may be insufficient treatment for skin abscesses.
What question this study addressed
After drainage of uncomplicated skin abscesses, does treatment with oral trimethoprim-sulfamethoxazole reduce treatment failure at 7 days?
What this study adds to our knowledge
This 212-adult, double-blind, randomized, controlled trial found similar rates of treatment failure in patients receiving antibiotics and placebo.
How this might change clinical practice
Antibiotics are unnecessary after abscess incision and drainage.
A. What is the current management of uncomplicated skin abscesses at your institution? Has management been influenced by the emergence of CA-MRSA infection cases? B. What is the evidence for treating uncomplicated skin abscesses with antibiotics?A. What were the outcomes for this study? Define “treatment failure?” How was treatment failure determined in this article?
A. Discuss three common types of trial design: superiority (conventional), non-inferiority, and equivalence trials.B. If you were designing this study which of these designs would you choose? Why? What would be your second choice? Why?C. What did the authors use? How might this affect interpretation of results?
D. Detail the difference between the null hypothesis in a conventional superiority trial and the null hypothesis in an equivalence (or non-inferiority) trial.A. What assumptions are required in order to assert that the difference and confidence interval are unbiased estimates of the true difference?B. What limitations could affect these assumptions and hence the interpretation of these numbers?A. Describe how a Bayesian approach might be used instead (hint: you do not need to do any calculations, just draw pictures).B. Discuss the pros and cons of such an approach.6. Taking into account the findings in the Schmitz et al article, the potential additional costs of treatment failure cases (bounce backs, emergency department administration of intravenous (IV) antibiotics, hospital admissions for IV antibiotics) and the potential complications of adverse reactions to trimethoprim-sulfamethoxazole (allergies, side effects), can you develop a compromise strategy to manage non-complicated skin abscesses?
Reference
Section editors: Tyler W. Barrett, MD, MSCI, Vanderbilt University Medical Center, Nashville, TN; David L. Schriger, MD, MPH, University of California, Los Angeles, CA
Editor's Note: You are reading the 17th installment of Annals of Emergency Medicine Journal Club. This bimonthly feature seeks to improve the critical appraisal skills of emergency physicians and other interested readers through a guided critique of actual Annals of Emergency Medicine articles. Each Journal Club will pose questions that encourage readers—be they clinicians, academics, residents, or medical students—to critically appraise the literature. During a 2- to 3-year cycle, we plan to ask questions that cover the main topics in research methodology and critical appraisal of the literature. To do this, we will select articles that use a variety of study designs and analytic techniques. These may or may not be the most clinically important articles in a specific issue, but they are articles that serve the mission of covering the clinical epidemiology curriculum. Journal Club entries are published in 2 phases. In the first phase, a list of questions about the article is published in the issue in which the article appears. Questions are rated “novice,” () “intermediate,” () and “advanced” () so that individuals planning a journal club can assign the right question to the right student. The answers to this journal club will be published in the February 2011 issue. US residency directors will have immediate access to the answers through the Council of Emergency Medicine Residency Directors Share Point Web site. International residency directors can gain access to the questions by going to http://www.emergencymedicine.ucla.edu/annalsjc/ and following the directions. Thus, if a program conducts its journal club within 5 months of the publication of the questions, no one will have access to the published answers except the residency director. The purpose of delaying the publication of the answers is to promote discussion and critical review of the literature by residents and medical students and discourage regurgitation of the published answers. It is our hope that the Journal Club will broaden Annals of Emergency Medicine's appeal to residents and medical students. We are interested in receiving feedback about this feature. Please email journalclub@acep.org with your comments.
PII: S0196-0644(10)01253-9
doi:10.1016/j.annemergmed.2010.07.023
© 2010 Published by Elsevier Inc.
Refers to erratum:
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