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APPLICATION CLINICAL META-ANALYSIS A. GOAL To be able to assess the validity and applicability of published meta-analyses, to appropriately apply them to the care of individual patients, and to understand some of reasons why meta-analyses of the same subject conducted in the same time period may come to different conclusions. B. CLINICAL SCENARIO Patients presenting with acute asthma symptoms constitute a major proportion of emergency department caseloads, particularly in inner cities. Treatment of asthma in the ED is focused on improving the patient s breathing by reversing the bronchoconstriction through the use of bronchodilator medications (the most common being the Beta 2 agonists albuterol). Additional bronchodilation may be achieved by using other complementary medications such as anticholinergics, corticosteroids and Magnesium (given intravenously). At morning rounds in the ED discussion was focused on a 33-year-old female patient that presented the evening before with an initially mild asthma exacerbation. During initial treatment (that consisted of albuterol) the patient developed severe bronchoconstriction that was not amenable to additional albuterol, oral corticosteroids, and oxygen. The patient went into acute respiratory distress requiring intubation and hospitalization. The attending physician was queried as to whether IV magnesium was given prior to intubation it was not. Debate ensued about the value of this treatment, and several people present citied various RCTs that apparently showed variable results (from no benefit, to positive and even negative outcomes). Someone also noted that a recent meta-analysis had shown that IV Magnesium had no positive effect, while someone else thought that a recent meta-analysis had proven the benefit of this treatment. You were asked to follow-up on these meta-analyses and report back to the group at the monthly journal club meeting week. next You searched MEDLINE using the terms ASTHMA as a MeSH and Keyword, and MAGNESIUM as a text term. You restricted the search to Meta-analysis and for the time period 2000 and 2001 only. You locate the 2 articles, one of which seemed to suggest magnesium was beneficial, while the other said it was not. C. TEACHING SCENARIO You are also aware of an old JAMA article by Oxman on the evaluation of meta-analyses or overviews. You decide to use this article to evaluate the two meta-analyses to try to determine why they came to different conclusions and whether either of the two studies have sufficient validity to be presented at the journal club. D. ARTICLES 1. Oxman AD, Cook DJ, Guyatt GH for the Evidence-Based Medicine Working Group. Users Guides to the Medical Literature VI. How to use an overview. JAMA 1994;272(17):1367-1371. 2. Alter HJ, Koepsell TD, Hilty WM. Intravenous magnesium as an adjuvant in acute bronchospasm. Ann Emerg Med 2000;36(3):191-97. 3. Rowe BH, Bretzlaff JA, Bourdon C, et al. Intravenous magnesium sulfate treatment for acute asthma in the emergency department: a systematic review of the literature. Ann Emerg Med 2000;36(3):181-90. CRITICAL REVIEW FORM FOR SYSTEMATIC REVIEW (META-ANALYSIS) Guide I. Are the Results Valid? 1. Did this review address a focused clinical question? 2. Were the criteria for article inclusion appropriate? 3. Is it unlikely that relevant studies were missed? 4. Was the validity of the included studies appraised? 5. Was the assessment of studies reproducible? 6. Were the results similar from study to study? II. What are the results? 1. What are the overall results of the review? 2. How precise are the results? III. Will the results help me in caring for my patients? 1. Can the results be applied to my patients? 2. Were all clinically important outcomes considered? 3. Are the benefits worth the harms and costs? Comments

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