June 2018

NICE Sore Throat:

Assessment, diagnoses not to miss, weird and wonderful causes, when to treat and the new FeverPAIN score.

Chris Connolly and Becky Maxwell

CAP9, CAP14, CAP31, PAP8, PAP19, PMP2

The first big change in this NICE CKS is that CENTOR is out. FeverPAIN is the score that’s now recommended.

FeverPAIN – score one for each of: 

Fever >38

Purulent exudate

Attends rapidly (3 days),

severely Inflamed Tonsils,

No Coryza

Score 4 out of 5 and there’s a 62-65% sensitivity for GAS

In terms of treatments for GAS. We believe that supportive care is best for most patients, and antibiotics should be reserved for the higher risk groups.

This can include the very old, the very young, those who are immunosuppressed and those at risk of rheumatic fever. NICE recommends not holding back on antibiotics for those with ‘severe’ tonsillitis, although don’t describe what this constitutes-we think this is probably those who are sick enough to warrant hospitalisation.

Remember that based on the Cochrane review that antibiotics only reduce symptom burden by around 16 hours.

Glandular Fever

Glandular fever guidance can be found in the refs section.

Avoid kissing

Avoid contact sport for 6 weeks

Blood tests can be useful here

Manage and set the patients expectations in terms of how long it will take to get better!

There have been mall outbreaks of measles in the UK sadly. It has big implication for patients and staff. If your staff are exposed they will need to ‘prove immunity’ and may be barred from clinical work for 21 days.

Measles

Signs and symptoms of measles include

Conjunctivitis

Rhinitis

Cough

Maculopapular morbilliform rash.

Koplick spots

Kawasaki Disease

Cause is still unknown

You need 5 out of 6 of these features for diagnosis:

Fever for >5 days without cause

Bilateral conjunctivitis

Oral mucosal changes – fissures and redness

lymphadenopathy

Poly-morphous rash

Extremity changes – erythematous palms and soles.

References

cks.nice.org.uk glandular fever

cks.nice.org.uk sore throat acute

www.cochrane.org ARI antibiotics people sore throats

New in EM Paper One – Steroids for treatment of Urticaria

Will the addition of steroids to an antihistamine help to resolve urticaria?

CAP28

Andy Neill, Dave McCreary

Clinical question: 

Will the addition of steroids to an antihistamine help to resolve urticaria?

Paper

Levocetirizine and Prednisone Are Not Superior to Levocetirizine Alone for the Treatment of Acute Urticaria: A Randomized Double-Blind Clinical Trial

Author

Barniol, 2018

Background

We see lots of urticaria, often diffuse and incredibly itchy and miserable. usually there’s no clear precipitant and we keep adding drugs to try to make these patients less miserable. A short course of oral steroids is one of the most common interventions after an antihistamine. This is mainly based on data from the days of the first generation antihistamines and given that we now have fancy ones maybe the steroids don’t help much

Methods

This is a French RCT in a couple of EDs. Placebo controlled and double blind. Yay

Included if there was a “diffuse generalised rash characterised by weals and itching.” No great diagnostic criteria here but we all know what they mean

Primary outcome was complete resolution of itching at 2 days (which seems optimistic – patients would be interested to know if they were improved, not necessarily better)

Randomised to levocetirizine 5mg plus placebo or levo 5mg plus steroids for 5 days

Powered for a 30% absolute reduction – which seems optimistic

Results

80 patients 

60% resolution vs 70% favouring no steroids!! (which is statistically non significant)

Thoughts

These are antihistamine naive patients. So the take home is it’s probably OK to just use antihistamines as a first intervention – if they fail then you can still try steroids.

Following on from our successful aortic dissection podcast last month, our friendly radiologist approached us and wanted to get involved. 

During this podcast we discuss Acute Aortic Syndrome from a radiology point of view, the following is a summary of the main take home points: 

• Huge increase in scans (probably a good thing) 
• Refer to patients on request as ? acute aortic syndrome – spectrum of disease from aortic ulcers, mural wall thrombus to dissection – all form part of acute aortic syndrome. By putting this on a request form, the radiology registrar will look for this and comment on during the report. Pain that patient describes with acute aortic syndrome is similar and canno0t be distinguished therefore this is what we should be excluding. The reporting radiologist must be clear of the findings and be clear about the consequences of their findings in the report
• CXR – should not be first line investigation 
• ECHO – TOE high sensitivity and specificity but not ideal in all patients 
• CT – should be first line investigation – if negative for acute aortic syndrome may diagnose other pathologies once scan is negative for acute aortic syndrome – coronary occlusion, perfusion defects left ventricle, pericarditis, pneumonia not visible to Chest X-ray
• Remember the “retro-spectroscope” is the radiologists friend, go back and discuss reimaging or reviewing of recent scans of patient has ongoing CP or represents with similar pain
• Accurate imaging is key to acute artic syndrome and the British Society of Cardiovascular Imaging (BSCI)/British Society of Cardiovascular CT (BSCCT) produced these guidelines in 2016 about how best to image 
• We you have a potentially life threatening condition you should not worry about having a test that is normal. We don’t worry about doing CT head on patients on antiplatelet. Why would we not image condition such as acute aortic syndrome which has such a high mortality? 
• Not always easy for EP to have a clear question re the diagnosis acute aortic syndrome versus PE etc. Chest pain is primarily a radiology consideration in terms of diagnosis. 

Epistaxis with St Mungos

Epistaxis management from an expert.

Eoghan Colgan and Gerry McGarry

HAP12, PAP8

This segment first appeared on the St Mungo’s Podcast in late May 2018

stmungos-ed.com

Following on from our successful aortic dissection podcast last month, our friendly radiologist approached us and wanted to get involved.

During this podcast we discuss Acute Aortic Syndrome from a radiology point of view, the following is a summary of the main take home points:

• Huge increase in scans (probably a good thing)
• Refer to patients on request as ? acute aortic syndrome – spectrum of disease from aortic ulcers, mural wall thrombus to dissection – all form part of acute aortic syndrome. By putting this on a request form, the radiology registrar will look for this and comment on during the report. Pain that patient describes with acute aortic syndrome is similar and canno0t be distinguished therefore this is what we should be excluding. The reporting radiologist must be clear of the findings and be clear about the consequences of their findings in the report
• CXR – should not be first line investigation
• ECHO – TOE high sensitivity and specificity but not ideal in all patients
• CT – should be first line investigation – if negative for acute aortic syndrome may diagnose other pathologies once scan is negative for acute aortic syndrome – coronary occlusion, perfusion defects left ventricle, pericarditis, pneumonia not visible to Chest X-ray
• Remember the “retro-spectroscope” is the radiologists friend, go back and discuss reimaging or reviewing of recent scans of patient has ongoing CP or represents with similar pain
• Accurate imaging is key to acute artic syndrome and the British Society of Cardiovascular Imaging (BSCI)/British Society of Cardiovascular CT (BSCCT) produced these guidelines in 2016 about how best to image
• We you have a potentially life threatening condition you should not worry about having a test that is normal. We don’t worry about doing CT head on patients on antiplatelet. Why would we not image condition such as acute aortic syndrome which has such a high mortality?
• Not always easy for EP to have a clear question re the diagnosis acute aortic syndrome versus PE etc. Chest pain is primarily a radiology consideration in terms of diagnosis.

Clinical Question:
Can fluoroquinolones cause aortic badness?
Title of Paper:
Fluoroquinolone use and risk of aortic aneurysm and dissection: nationwide cohort study
Journal and Year:
BMJ 2018
Lead Author:
Bjorn Pasternak
Background
Fluoroquinolones (Ciproxfloxacin and friends) are frequently prescribed antibiotics
They are known to be associated with tendon disorders such as Achilles tendon rupture
They have been shown to induce collagen degradation and other structural components of the extracellular matrix by stimulation of matrix metalloproteinases
Rupture or dissection of the aorta is bad
Aorta integrity depends on intact extracellular matrix
Pathophysiology of aortic aneurysm is known to involve tissue breakdown through matrix metalloproteinases
Patients Studied:
All patients ≥ 50 years old in Sweden who were prescribed fluroquinolones or amoxicillin with:
No previous aortic pathology
No study abx for preceding 120 days
No hospital admission preceding 120 days
No other abx prescribed on same day
No end stage illness, drug or alcohol abuse
Had used at least one prescription drug in past year to ensure engagement in healthcare system
Intervention / Comparison:
Fluroquinolone vs Amoxicillin
Outcome:
Primary outcome: First diagnosis of aortic aneurysm or dissection within 60 days of filling prescription
Summary of Results:
360,088 patients in each group for analysis
Majority of fluoroquinolone use was ciprofloxacin (78%), followed by norfloxacillin (20%)
Primary outcome:
Fluoroquinolone group: 64 cases aortic aneurysm or dissection (incidence 1.2 per 1000 person years)
Amoxicillin group: 40 cases aortic aneurysm or dissection (incidence 0.7 per 1000 person years)
Increased risk of aortic aneurysm/dissection at 60 days with HR 1.66 (95%CI 1.12-2.46)
Authors’ Conclusion:
Fluoroquinolone use was associated with an increased risk of aortic aneurysm or dissection with the difference largely driven by aortic aneurysm.
Clinical Bottom Line:
There may be a link between fluoroquinolones and aortic disease, but causality is yet to be proven and even if it was the difference is teeny weeny (82 extra cases per million treatment episodes). Not a practice changer by far, but interesting nevertheless. As you were.
Other links / references:
A good editorial was published alongside it which is worth a read