Best Evidence Topics


Stell IM
Management of acute bursitis: outcome study of a structured approach
Journal of the royal society of medicine
  • Submitted by:Simon Carley - Consultant in Emergency Medicine
  • Institution:Manchester Royal Infirmary
  • Date submitted:5th February 2004
Before CA, i rated this paper: 5/10
1 Objectives and hypotheses
1.1 Are the objectives of the study clearly stated?
  Yes, this was a prospective case series of management of bursitis. All patients had a diagnostic tap. Patient were then followed up long term to see what the underlying cause and subsequent clinical course was.
2 Design
2.1 Is the study design suitable for the objectives?
  Yes. The author has taken samples from all patients and then followed them through to see how many were septic. This study was not really looking at managememnt options, but did allow an explanation of aetiology.
2.2 Who / what was studied?
  All patients presenting with an acute bursitis to an ED (57 patients). 47 patients were included in the final analysis. 33 had olecranon bursitis, the rest had prepatellar bursitis.
10 patients were excluded from analysis for various reasons; though there were efforts to follow these patients up in 6 cases.
2.3 Was a control group used if appropriate?
  Not applicable
2.4 Were outcomes defined at the start of the study?
  In broad terms yes. This can be difficult in these cases. A panel of 2 senior docs, rheumatology & orthopaedic were used to determine diagnoses.
2.5 Was this the right sample to answer the objectives?
  Yes, relevant to clinical practice in UK EDs.
2.6 Is the study large enough to achieve its objectives? Have sample size estimates been performed?
  No sample size estimate made. This is a small study and the estimates will have wide confidence intervals (though none are reported).
2.7 Were all subjects accounted for?
  No 10 were lsot because of protocol violation, lack of diagnostic material or previous antibiotics.
2.8 Were all appropriate outcomes considered?
2.9 Has ethical approval been obtained if appropriate?
  Not mentioned.
3 Measurement and observation
3.1 Is it clear what was measured, how it was measured and what the outcomes were?
  Sepsis seems to be defined in terms of growth from sampoles taken which is a good gold standard.
Long term outcome (at 12-18 months) was assessed by phone which gives the patients perspective only.
3.2 Was the assessment of outcomes blinded?
3.3 Was follow up sufficiently long and complete?
  Yes up to 18 months by phone. 38/47 patient had long term follow up data.
3.4 Are the measurements valid?
3.5 Are the measurements reliable?
3.6 Are the measurements reproducible?
4 Presentation of results
4.1 Are the basic data adequately described?
  Yes. Good tabuilation of basic data.
4.2 Are the results presented clearly, objectively and in sufficient detail to enable readers to make their own judgement?
4.3 How large are the effects within a specified time?
  The principle interesting finding here is the large proportion of patients with defined sepsis. Overall 15/33 of the olecranon patients had sepsis defined and 13 of the prepatellar patients had defined sepsis. This represents a significant rate of infection in these patients.
4.4 Are the results internally consistent, i.e. do the numbers add up properly?
5 Analysis
5.1 Are the data suitable for analysis?
  Only by descriptive stats. Confidence intervals would have been very useful here but are not reported.
5.2 Are the methods appropriate to the data?
5.3 Are any statistics correctly performed and interpreted?
6 Discussion
6.1 Are the results discussed in relation to existing knowledge on the subject and study objectives?
  Yes, the approach in this paper seems to reduce the need for admission with satisfactory clinical outcomes
6.2 Is the discussion biased?
7 Interpretation
7.1 Are the author's conclusions justified by the data?
  The study is too small to be conclusive. However, the author is really describving and auditing heir current practice. There is cewrtainly nothing here to indicate a change in practice.
7.2 What level of evidence has this paper presented? (using CEBM levels)
  Not sure
7.3 Does this paper help me to answer my problem?
After CA, i rated this paper: 5/10
8 Implementation
8.1 Can any necessary change be implemented in practice?
  We currently do not aspirate in all cases and have had no problems. Should we change? This paper suggests that we should to define the group with sepsis.
8.2 What aids to implementation exist?
  Information dissemination
8.3 What barriers to implementation exist?
  Problems of aspirating bursa in the relatively unclean environment of the ED.
8.4 Are the study patients similar to your own?
  I am not sure. The authors state that these were patients presenting to the ED, so they should be. However, my own experience suggests a much lower rate of infection (but there again I do not aspirate or give antibiotics routinely). So either 1, these patients are different OR 2, giving antibiotics does not matter even if they are infected.
8.5 Does the paper give any conclusions that will affect what you will offer or tell your patient?
  I may lower my threshold for aspiration if there is any siign of infection