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13th January 2023
Three screening-based predictive tools for COVID-19 used within an emergency department (ED) have been shown to be inferior to a polymerase chain reaction (PCR) test according to the results of a study by US researchers.
During the early phase of the COVID-19 pandemic, diagnostic testing was not always readily available. Consequently, there was a need for clinical decision-making methods to identify patients most likely to be infected with the virus. Some such methods were developed and one study using a risk score for COVID-19 diagnosis, achieved an area under the receiver operating characteristic curve of 0.85 in a validation dataset, prompting the authors to suggest that it could be used as a supplemental tool to assist in the clinical decision to quarantine patients admitted to hospital from the emergency room. Nevertheless, while there are several available methods, no studies have compared the performance of different methods to predict the likelihood that a patient presenting to an ED has COVID-19.
In the current study, the US team retrospectively assessed three screening-based methods to determine which was better at detecting those who ultimately tested positive for COVID-19. The three methods were a nursing triage screen (NTS), an ED review of systems (ROS) performed by physicians and physician assistants and a standardised COVID-19 probability assessment (PA) by an ED attending (i.e., consultant) physician. The study included all patients aged 18 years or older who were admitted to hospital from the ED and who had a PCR confirmed positive COVID-19 infection. The NTS for example, involved asking about the presence of symptoms including fever, chills, weakness, severe headache, anosmia, dysgeusia, conjunctival injection, sore throat, cough, shortness of breath (SOB), abdominal pain, vomiting, diarrhoea, bruising or bleeding, myalgia, arthralgia and rash. Similarly, the ED review of ROS asked about symptoms, whereas after the initial ROS (but before the COVID-19 test result was available), the attending physician would classify the patient as high, moderate, low or no probability of having COVID-19. The sensitivity, specificity and positive predictive value (PPV) and negative predictive value (NPV) were calculated for each method. and regression analysis used to assessed each tool’s performance.
Screening-based prediction and COVID-19 positivity
A total of 748 patients with mean age of 57.5 years (56.8% male) were included in the analysis. Overall, 21.3% of patients tested positive for COVID-19 following a PCR test.
The attending physician had the highest sensitivity (0.62, 95% CI 0.53 – 0.71), followed by the ED ROS (0.53, 95% CI 0.43 – 0.62) and the least sensitive was the NTS (0.46, 95% CI 0.37 – 0.56). Specificity values were also highest for the attending physician (0.76) though this was similar to the NTS (0.71) and lowest for the ED ROS (0.62). Nevertheless, all three methods had a low positive predictive value, ranging from 26% (ED ROS) to 40% (attending physician).
The authors concluded that none of the three screening-based tools was accurate enough to replace a COVID-19 PCR test, adding that hospitals should not rely symptom screening to identify infected patients and recommended universal COVID-19 testing prior to all admissions.
Dilorenzo MA et al. Performance of three screening tools to predict COVID-19 positivity in emergency department patients. Emerg Med J 2023
14th November 2022
Assessment of S100B levels in low-risk head injury patients seen in an emergency department is a potential diagnostic marker to rule-out serious intracranial pathology that reduces the need for a CT-head scan in more than a quarter of cases according to a study by New Zealand researchers.
In a 2016 study it was estimated that globally, there were 27·08 million new cases of traumatic brain injury (TBI) caused primarily by falls and road injuries. Moreover, assessing patients with a head injury in an emergency department (ED) takes time with and has been estimated at 6.6 hours with the time related to head CT responsible for about half of the total length of stay. Despite increased availability of CT scans and its potential value as a diagnostic tool, over 90% of head CT scans in those referred from ED to exclude a significant intracranial injury have been found to be normal prompting the search for alternative assessment tools. One potential biomarker protein is S100B, which has been described as a useful neuro-biochemical marker of brain damage such as in circulatory arrest, stroke and traumatic brain injury. However, a recent systematic review concluded that the diagnostic accuracy of single biomarkers as a rule out for significant intracranial injury seen on CT head scans in ED patients with TBI is low. Nevertheless, the authors of the review added that S100B is the only single biomarker with a validated clinical platform making it the biomarker of choice. Despite this, there is little evidence on the diagnostic performance of S100B, particularly in low-risk head injury patients, where it is likely to be of greatest value in reducing the need for a CT-head scan.
In the present study, the New Zealand team examined the diagnostic value of the biomarker for excluding significant intracranial pathology in patients who presented at an ED within 6 and 24 hours of their head injury. Included patients were those able to give consent and without signs of post-traumatic amnesia and blood samples were taken to measure S100B levels. All patients were assessed and sent for a CT-head scan when deemed clinically appropriate and categorised as CT-positive (i.e., needing a scan) or CT-negative. The primary outcome was the diagnostic accuracy of S100B within 6 hours after a head injury.
S100B diagnostic value in low-risk head injury
A total of 265 patients of whom, 133 with a median age of 69.5 years (35.8% female) presented within 6 hours of their head injury were included in the study.
Among those presenting within 6 hours, the median S100B level in those who were CT-positive was 0.36 and compared to 0.15 in the CT-negative group (p < 0.01). The sensitivity of S100B in the 6-hour group was 93.8% and the specificity of 30.8%.
The authors calculated that using a clinically validated cut-off threshold for S100B of 0.1 μg/mL, if patients with levels below this threshold did not have a CT-head scan, the use of scans would be reduced by 27.1%. Similarly, for those attending within 24 hours of their head injury and using the same threshold, would lead to a 37.4% reduction in CT scans. In fact, the authors also determined that the risk of missing a significant injury with this approach would result in missing only 0.75% of significant injuries within 6 hours or 2.3% within 24 hours.
They concluded measurement of S100B performed well as a diagnostic aid to exclude significant intracranial injury in low-risk patients with a head injury.
Rogan A et al. Diagnostic performance of S100B as a rule-out test for intracranial pathology in head-injured patients presenting to the emergency department who meet NICE Head Injury Guideline criteria for CT-head scan Emerg Med 2022
11th November 2022
Using two separate frailty assessment scores on emergency department patients helps to identify different at-risk patient cohorts and highlights the potential benefit of using both to guide clinical decision-making according to Saudi Arabian researchers.
The term frailty is related to the ageing process and associated with adverse health outcomes. For example, among general surgical patients, the prevalence of frailty has been estimated to range from 10.4 and 37.0% and with a 30-day mortality rate of 8%. Among emergency department (ED) patients, identification of frailty may help guide clinical practice, especially given how the prevalence of frail patients encountered in ED ranges from 9.7% to 43.7%. The Clinical Frailty Scale (CFS) is a recognised frailty assessment tool that can be used to assess the risk of death in patients and has been shown to be an accurate score for predicting poor outcomes and is more practical for use in busy clinical environments such as an ED. An alternative frailty assessment tool is the Hospital Frailty Risk Score (HFRS) and which provides health systems with a low-cost, systematic way to screen for frailty and identify patients at greater risk of adverse outcomes. However, the predictive accuracy of HFRS has not been assessed within an ED and for the present study, the Saudi researchers set out to retrospectively determine the extent to which the CFS and HFRS correlated and their ability to predict adverse hospital-related outcomes for older adults attending an ED. The team developed logistic regression models to estimate the odds ratios (ORs) for both tools to predict both 30-day mortality, a length of stay > 10 days and 30-day remission.
Frailty assessment and clinical outcomes
A total of 12,237 patients with a mean age of 84.6 years (57.8% female) were eligible for inclusion in the analysis.
The correlation between two frailty assessments was low at 0.36 (95% CI 0.34 – 0.38) and the agreement between them was also poor (weighted kappa = 0.10, 95% CI 0.09 – 0.11).
In fully adjusted models, the estimates of 30-day mortality were similar between both frailty assessment tools for patients deemed at a high-risk of frailty (OR = 2.26 vs 2.16, CFS vs HFRS respectively).
The authors concluded that both tools were shown to be predictors of adverse outcomes but given the low level of agreement, each tool was actually identifying a different at-risk population, and which highlighted the potential value of using each tool in ED to help guide clinical decision-making.
Alshibani A et al. A comparison between the clinical frailty scale and the hospital frailty risk score to risk stratify older people with emergency care needs. BMC Emerg Med 2022
3rd November 2022
Opiates and non-steroidal anti-inflammatory drugs (NSAIDs) provide a similar level of pain relief for patients with musculoskeletal pain who present at an emergency department according to the findings of a meta-analysis by researchers from Sydney, Australia.
Opiates can be prescribed to patients within an emergency department (ED) who present with pain though one US study suggested that most opioid prescribing originates from primary care with a smaller proportion from EDs. However, other studies indicate that opiates (opioids) are probably used more often especially since in a 2020 study of an Australian tertiary hospital in Victoria, concluded that opioid prescribing was common with almost one-quarter of discharge prescriptions being for a prescription opioid. In another study, this time from a US hospital, of 19,321 discharged patients, 17% received an opioid pain reliever prescription. The value of opioids in the management of musculoskeletal pain was addressed in a 2020 American College of Physicians and American Academy of Family Physicians clinical guide and which clearly advises ‘against clinicians treating patients with acute pain from non–low back, musculoskeletal injuries with opioids, including tramadol.‘ The comparative efficacy of opiates and other analgesics in non-low back, musculoskeletal injuries were examined in a 2020 systematic review which concluded on how no opioid achieved benefit greater than that of NSAIDs, adding how opioids caused the most harms. Nevertheless, there is a lack of data on the efficacy of opiates for relief of musculoskeletal pain within an ED setting. Consequently, the Australian team decided to evaluate the effectiveness and safety of opioid analgesics compared with placebo, paracetamol and other non-opiates during an ED stay. The team searched all of the major databases and included randomised, controlled trials in adults with musculoskeletal pain (e.g., sprains, muscle aches, ligament, tendons, bone in the case of fractures) who attended an ED. They set the primary outcome as pain intensity at follow-up of approximately 2 hours after administration of treatment and which was measured on a 100 mm visual analogue scale.
Opiates and comparative pain relief
A total of 42 articles with 5765 participants and a mean age of 41 years (37.6% female) were included in the analysis.
The reduction in pain relief from opiates after 2 hours, was statistically superior to placebo (mean difference, MD = -6.3, 95% CI -10.5 to -2.2) and paracetamol (MD = -6.7, 95% CI -11.9 to -1.5). However, the difference with NSAIDs was not significant (MD = -0.1, 95% CI -2.5 to 2.3) although opioids were far less effective than local anaesthetics (MD = 17.3, 95% CI 1.5 to 33.1). Overall, there was no evidence of a clinical or statistical difference between opioids and non-opioids for pain relief at either 0.5 or 12 hours after dosing.
With respect to adverse events, opioid patients were at a higher risk than those receiving placebo (14%), paracetamol (7.2%) or NSAIDs (21.4%).
Despite these findings, the authors concluded that the risk-benefit balance of opiates compared to placebo, paracetamol, NSAIDs and local anaesthetics remains uncertain. They added that while opiates have equivalent pain outcomes to NSAIDs, the evidence on harm is uncertain and heterogenous.
Jones CMP et al. Effectiveness of Opioid Analgesic Medicines Prescribed in or at Discharge From Emergency Departments for Musculoskeletal Pain : A Systematic Review and Meta-analysis Ann Intern Med 2022
24th October 2022
Short-term fluoroquinolone use does not result in a higher risk of either emergency department (ED) visits or hospital admission for suicidality when treating either pneumonia or a urinary tract infection (UTI) compared to other antibiotics. This was the main finding of an analysis using a national commercial US health insurance claims database by US researchers from Boston.
The safety of fluoroquinolones has been under the spotlight for many years. In 2016, the US food and Drug Administration (FDA) issued a safety announcement in which it was reported that as a class, the medicines were associated with disabling and potentially permanent side effects of the tendons, muscles, joints, nerves, and central nervous system that can occur together in the same patient. Serious potential central nervous system adverse effects listed by the FDA include anxiety, depression, hallucination, confusion and suicidal thoughts. Similarly in Europe, the Pharmacovigilance Risk Assessment Committee has also suggested that healthcare professionals should advise patients to stop treatment with a fluoroquinolone antibiotic at the first sign of a side effect involving muscles, tendons or bones or the nervous system, including suicidal thoughts.
But how common is suicidal ideation among the general population of patients prescribed fluoroquinolones, particularly in the short-term, was the question posed by the US team in the present study. Equally important, was whether this risk of suicidality was sufficient to warrant either an ED visit or hospital admission and, if the risk was any higher than any clinically appropriate comparator drugs. The researchers focused on pneumonia and a UTI since fluoroquinolones are often used in the management of both indications. Several fluoroquinolones were analysed including ciprofloxacin, levofloxacin, moxifloxacin, gemifloxacin and ofloxacin. The researchers chose azithromycin and trimethoprim-sulfamethoxazole as comparator drugs for the pneumonia and UTI cohorts since these are commonly used alternatives for the two conditions. Participants were then matched 1:1 within each cohort. The study outcome of interest was suicidality which they defined as any hospital admission or emergency department visit and participants were followed-up for a maximum of 60 days after starting treatment.
Fluoroquinolone use and suicidality
A total of 825,420 patients with pneumonia and 3,463500 with a UTI were included in the analysis. The mean age of pneumonia participants was 51.4 years (48.6% male) although the UTI cohort were slightly younger (mean age 43.6 years, 8.4% male).
Overall, 0.03% of both fluoroquinolone and azithromycin users were either admitted to hospital or an ED for suicidality during follow-up. Among the UTI cohort, an identical proportion (0.04%) of both fluoroquinolone and trimethoprim-sulfamethoxazole users experienced suicidality resulting in an admission or ED visit. There was no significant difference among the pneumonia (Hazard ratio, HR = 1.01, 95% CI 0.76 – 1.36) and UTI (HR = 1.03, 95% CI 0.91 – 1.17) cohorts. These findings were consistent across the different subgroups based on sex, age or with a history of mental illness.
The authors concluded that the use of fluoroquinolones was not associated with a higher risk of suicidality leading to an ED visit or hospital admission compared to either azithromycin or trimethoprim-sulfamethoxazole. However, they added the caveat that it was not possible to exclude a small increased risk or on suicidal thoughts that did not lead to either an ED visit or hospital admission.
16th September 2022
An emergency department (ED) paracetamol overdose protocol with a treatment duration of only 12 hours, significantly reduced the length of hospital stay and may become more widely adopted according to the findings of a retrospective analysis by researchers based at the Emergency Department, University Hospitals Plymouth, UK.
Paracetamol is one of the most popular over-the-counter medicines worldwide although overdosing of the drug leads to hepatotoxicity and is a frequent cause of acute liver failure. Treatment for overdose relies on the use of acetylcysteine and which has been shown to be effective since the 1970’s.The standard acetylcysteine regimen includes three, separate, weight-related infusions over different timeframes and lasts anywhere between 20 to 25 hours. In 2012, a study examined a modified 12-hour Scottish and Newcastle Antiemetic Protocol (SNAP) and resulted in less vomiting, fewer anaphylactoid reactions, and a reduced need for treatment interruption. However, the authors of the study recognised that their study was not powered to detect the non-inferiority of the shorter protocol versus the standard 21-hour approach and suggested that further research was needed to confirm the efficacy of the 12 hour modified regimen. Since 2021, the Royal College of Emergency Medicine has recommended that the use of the SNAP regime to treat paracetamol toxicity should become the default standard practise in all emergency departments. However, to date, there has been no external validation of the protocol and this was the aim of the current retrospective analysis by the UK team. They reviewed hospital charts for patients aged 16 years and older who presented to the ED with confirmed or suspected paracetamol poisoning and who received both the standard 21-hour protocol and the modified SNAP. The primary objective was to identify if the use of SNAP reduced the duration of hospital stay.
Paracetamol overdose protocol and length of stay
A total of 294 patients with a mean age of 29.5 years (68.8% female) were included in the analysis, 76 of who were managed using SNAP. The paracetamol dose ingested was slightly higher among those using SNAP though not significantly different (241 mg/kg vs 223 mg/kg, p = 0.09).
The use of SNAP was a associated with a statistically significant reduction in hospital length of stay, median 29.3 hours vs 38.1 hours (SNAP vs 21-hour protocol, p < 0.012).
There was also a reduced incidence of anaphylactoid reactions (5.3% vs 15.4%, SNPA vs 21-hour protocol) and a lower number of patients requiring extended infusions (7.9% vs 9.2%).
The authors concluded that use of SNAP reduced the duration of inpatient admission and the rate of anaphylactoid reactions.
Humphries C et al. SNAPTIMED study: does the Scottish and Newcastle Antiemetic Protocol achieve timely intervention and management from the emergency department to discharge for paracetamol poisoning? Emerg Med J 2022
An Anticoagulant (AC) pathway for patients with atrial fibrillation seen at an emergency department can be easily and safely implemented before they are discharged home according to the findings of a study by Canadian researchers.
Atrial fibrillation (AF) is the most frequent cardiac arrhythmia and using a Global Health Data Exchange database, a study has revealed that total of 3.046 million global new cases were registered in the database during 2017. This same study also found that the worldwide prevalence of AF was 37,574 million cases (0.51% of worldwide population) and had increased by 33% during the last 20 years. Having AF leads to a 5-fold increased risk of stroke and that 20–30% of all strokes are attributed to the arrhythmia. In the UK, NICE has recommended the use of an anticoagulant for stroke prevention, noting how for most people the benefit of anticoagulation outweighs the bleeding risk. Given the importance of anticoagulation among AF patients, in a review of health records of patients diagnosed with new onset atrial fibrillation in two emergency departments, the Canadian group found that only 17% of 272 patients eligible for initiation of anticoagulation left the emergency department with a prescription for the treatment. Based in these findings, the team introduced the Safe Anticoagulation for Atrial Fibrillation (SAFE) emergency department (ED) pathway, for the initiation of treatment in patients with AF. The SAFE pathway used the CHADS65 risk stratification tool i.e., for which patients with heart failure, hypertension, diabetes, prior stroke or 65 years of age and over, were eligible. The SAFE pathway outlined the contraindications to starting a direct action oral anticoagulant (DOACs), provided patient educational material and a letter for their family doctor. For the study, the team set the primary outcome as the proportion of CHADS65-positive patients, without contra-indications to DOACs who received an AC and patients were followed up over the next 90 days.
Initiation of the anticoagulant pathway
Between 2018 and 2020, a total of 311 patients with a median age of 69 years (48% female) were managed using the SAFE pathway although since 8 were already prescribed an anticoagulant, the final number of patients included was 303.
An AC prescription was offered to 91.4% of the target population (4 declined treatment) and the 90-day anticoagulation status was available for 93% of patients.
Among the target group, 80.9% of patients were still taking their anticoagulant at 90 days and only a single patient was diagnosed with a stroke during this time-frame. Furthermore, the 90-day major bleed rate among those who had started treatment was 0.5%.
The authors concluded that the SAFE pathway facilitated anticoagulation among ED patients with AF at risk of stroke and with a low 90-day adverse event rate.
Kirwan C et al. Starting anticoagulation for atrial fibrillation in the emergency department safely Emerg Med J 2022
18th August 2022
The nebulised steroid budesonide in addition to intravenous hydrocortisone hemisuccinate, is no better than saline at improving peak expiratory flow or other relevant outcomes in patients with acute asthma presenting at an emergency department, according to the findings of a randomised, controlled trial by Tunisian and Chinese researchers.
Although the use of either injectable or oral systemic corticosteroids (steroids) is recognised as an effective treatment for the resolution of acute asthma symptoms, an alternative is the use of an inhaled or nebulised steroid, especially when used in conjunction with either intravenous or oral steroids. However, a 2012 Cochrane review concluded that while the early use of inhaled steroids reduces hospital admissions in patients with acute asthma who are not treated with oral or intravenous corticosteroids, there is insufficient evidence that such combinations led to clinically important changes in pulmonary function or clinical scores. There is evidence that in combination with nebulised short-acting bronchodilators, addition of the nebulised steroid, budesonide resulted in clinical improvement in children with moderate-to-severe acute exacerbation of asthma.
For the present study, researchers undertook a randomised, placebo-controlled trial and for which the working hypothesis was that a nebulised steroid combined with a systemic steroid would be more effective at managing pulmonary symptoms than the systemic steroid alone. They specifically examined high dose and repeated inhaled budesonide in combination with intravenous hydrocortisone hemisuccinate in the treatment of adult patients with acute asthma presenting at an emergency department (ED). The research team recruited adult patients diagnosed with acute asthma and who had a peak expiratory flow (PEF) rate of less than 50% of the predicted value, which is indicative of severe narrowing of the large airways and hence a medical emergency. Participants in the intervention arm received nebulised terbutaline 5mg in combination with ipratropium 0.5mg and 0.5mg budesonide followed by frequent use of budesonide and terbutaline after 20, 40, 60 and 120 minutes. In the placebo arm, participants received the same treatment, although budesonide was replaced with saline. For all patients PEF, respiratory rate (RR) and heart rate were measured before and after the different periods of time. The primary outcome of interest was the improvement in PEF and reduction in hospital admission rate, whereas the secondary outcomes included RR and heart rate.
Nebulised steroid and asthma outcomes
A total of 54 participants were randomised to budesonide (23, mean age 38 years, 39% male) or saline.
The average PEF at 180 minutes was 308l/min and 321l/min in the budesonide and control group respectively, representing a 139% and 121% increase from baseline and this difference of 18% was non-significant (95% CI -62 to 98%). In fact, there were no time-points when this difference was statistically significant. Furthermore, changes in RR, heart rate and all other secondary outcomes were also not significantly different between the two groups. Finally, hospitalisation rates were 40% for the nebulised steroid group and 38% for saline and, again, this difference was not significantly different (p = 0.88).
The authors concluded that addition of nebulised steroid to systemic steroids provided to additional benefit compared to systemic steroids alone in adult patients with acute asthma presenting to an ED.
Marghli S et al. Nebulized budesonide combined with systemic corticosteroid vs systemic corticosteroid alone in acute severe asthma managed in the emergency department: a randomized controlled trial BMC Emerg Med 2022
17th August 2022
The presence of an emergency department (ED) pharmacist as part of the clinical care team leads to improvements in the quality of medicines use according to the findings of a systematic review and meta-analysis by researchers from the School of Pharmacy and Pharmacology, University of Tasmania, Hobart, Tasmania, Australia.
The term ‘quality use of medicines’ (QUM) encompasses the wise selection of management options and choosing suitable medicines where indicated, together with ensuring that patients and carers have the knowledge and skills to use medicines safely and effectively. However, ensuring QUM within a busy emergency department is challenging with one analysis covering the period 2011 to 2020 finding that the most common prescribed medications mentioned in reports were epinephrine, insulin, hydromorphone, sodium chloride, heparin, Propofol, diltiazem, ketamine, and morphine. Furthermore, serious medication error events occurred most often at the prescribing stage (42.0%) with the most common medication error type being an incorrect dose (42%). Such errors might be reduced by having an ED pharmacist incorporated into the clinical team and there is already some evidence from a 2019 systematic review which concluded that pharmacy-led medication reconciliation significantly decreased the number of medication discrepancies. Nevertheless, the authors of the systematic review also noted how only one study investigated potential adverse drug events in patients receiving ED care and called for further studies to investigate the direct clinical impact of decreased medication discrepancies. Given that the impact and value of an ED pharmacist remains to be fully explored, for the present study, the Australian team undertook a systematic review and meta-analysis, specifically focusing on the effect of adult care, when departments had access to a pharmacist as part of the ED team.
A literature search was designed to uncover studies in which a pharmacist was a part of the ED team and where the impact was compared with usual care. The outcomes considered were changes in the rates or proportions of the medication-related outcomes such as medication errors, the appropriateness of prescribed medicines, length of hospital stay or re-admission.
Emergency department pharmacist and medication-related outcomes
The literature search identified a total of 31 eligible studies and which included 13,242 participants and with individual study sample sizes ranging from 34 to 3,594. The types of included studies were pre-post interventions, cohort studies and randomised, controlled trials.
Not every study could be used for all of the outcomes under examination. However, pooling results from 10 studies showed that an ED pharmacist intervention was associated with an average error rate decrease of 0.33/patient (95% CI -0.42 to -0.23, p < 0.001). Similarly, in a meta-analysis of 10 studies, use of emergency department pharmacists were associated with a 73% lower proportion of patients with at least one error (relative risk, RR = 0.27, 95% CI 0.19 – 0.40, p < 0.001).
Analysis of 7 studies indicated a 58% increased appropriateness of prescribing (RR = 1.58, 95% CI 1.21 – 2.06, p < 0.001) after input from pharmacists. Finally, there was a 30% reduced risk of re-presenting to ED (RR = 0.70, 95% CI 0.52 – 0.94, p = 0.02) and a 38% reduced risk of re-admission (RR = 0.62) after intervention by a pharmacist.
The authors concluded that their data showed how an ED pharmacist improved QUM and called for future studies to examine the cost-effectiveness of ED-based pharmacy interventions.
Atey TM et al. Impact of pharmacist interventions provided in the emergency department on quality use of medicines: a systematic review and meta-analysis Emerg M J 2022
16th August 2022
The addition of acupuncture to intramuscular diclofenac for emergency department patients with renal colic gave rise to a rapid and substantial reduction in pain according to the findings of a sham-controlled, randomised trial by Chinese researchers.
Renal or ureteric colic describes the acute and severe loin pain caused when urinary stones (urolithiasis) move from the kidney or obstruct the flow of urine. In fact, according to the European Association of Urology (EAU) guidelines, renal colic due to ureteral stone obstruction is an emergency that requires immediate pain management. The EAU recommends the use of non-steroidal anti-inflammatory drugs (NSAIDs) for pain management in renal colic and in a 2018 systematic review, the authors concluded that treatment of renal colic with NSAIDs offers effective and sustained pain relief, with fewer side effects, when compared with opioids or paracetamol. The use of traditional Chinese medicine and, in particular, acupuncture has been practised for several thousand years and there is evidence that it is effective for the treatment of chronic musculoskeletal, headache, and osteoarthritis pain. Moreover, treatment effects persist over time and cannot be explained solely in terms of placebo effects. Furthermore, acupuncture has been used for the management of renal colic and was found to provide a higher rate of pain relief than intravenous morphine. In a further comparative trial, it was found that acupuncture provided a similar level of pain relief to intravenous diclofenac after 2 hours.
However, while the available data demonstrates the value of acupuncture in comparison to other analgesics used in renal colic, the benefit of acupuncture as an adjunctive therapy with NSAIDs has not been explored and was the subject of the present Chinese study. The researchers performed a sham-controlled, randomised trial at the emergency department of Beijing Hospital and recruited patients with acute renal colic and which had been confirmed by radiography or ultrasound examination within the previous 24 hours. Participants who had moderate to severe colic (a score of 4 or more on a 10-point visual analogue scale (VAS) were enrolled and all received 25mg diclofenac given intramuscularly. They were then equally randomised to 30 minutes of either sham or genuine acupuncture. The primary outcome was the response rate at 10 minutes after needle manipulation, defined as the proportion of participants whose VAS pain score reduced by at least 50%. The researchers also examined the change in pain relief after 20, 30, 45 and 60 minutes of needle manipulation as well as the proportion requiring rescue medication with intravenous morphine.
Acupuncture and pain relief
A total of 80 participants with a mean age of 45.8 years (82.5% male) were given intravenous diclofenac and randomised to acupuncture or sham procedure.
After 10 minutes, 77.5% of those receiving acupuncture compared to 10% receiving sham treatment achieved the primary outcome and this difference of 67.5% was significant (p < 0.001). A difference in pain relief favouring acupuncture was evidence up to 30 minutes although by 45 and 60 minutes, the two groups were similar. Moreover, there were no adverse reactions in the sham or acupuncture groups.
Despite the fast and substantial improvement associated with the use of acupuncture, there were no differences in the need for rescue medication. The researchers concluded that acupuncture provides fast and effective pain relief of renal colic and should be considered as an optional adjunctive therapy for the condition.
Tu JF et al. Effect of Adjunctive Acupuncture on Pain Relief Among Emergency Department Patients With Acute Renal Colic Due to Urolithiasis: A Randomized Clinical Trial JAMA Netw Open 2022