May 2016: New in EM

Paper Chosen by: Craig Davidson

Clinical Question: Are retrospective studies examining the utility of whole body CT in major trauma Exaggerating it’s impact on mortality?

1st Author: Malkeet Gupta

Journal: Annals of EM

PMID: 25964085

Title: Injury Severity Score Inflation Resulting From Pan-Computed Tomography in Patients With Blunt Trauma.

Patients studied: Adult blunt trauma patients in level 1 trauma centre in LA, USA.

Intervention: WBCT

Comparison: selective CT (sort of)

Outcomes: ISS score with selective CT vs WBCT

Strengths: Questions the dominant trend of early whole body CT in trauma

Weaknesses: Single centre ISS lower overall than in previous studies suggesting benefit

Clinical bottom line:

1. WBCT when done indicriminately likely artifically increases ISS score making people look sicker than maybe they are
2. WBCT most likely to be of benefit in severely injured patients but not in others
3. WBCT shouldn’t be used as a substitute for hx/clinical examination
4. REACT 2 is coming (RCT)

References/Kudos:

• Annals audio podcast
• EM Nerd

Paper Chosen by: Andy Neill

Clinical Question: How often can we find a treatable cause for dementia?

1st Author: Djukic

Journal: European Archives of Psychiatry and Clinical Neuroscience

PMID: 25716929

Title: Frequency of dementia syndromes with a potentially treatable cause in geriatric in‐patients: analysis of a 1‐year interval

Patients studied: 166 pts admitted to a geriatrics ward in Germany with suspected dementia (2/3 prior diagnosis, 1/3 new diagnosis)

Outcomes: rate of potentially treatable causes of dementia

Strengths: important question; relevant population (esp both new and established diagnoses)

Weaknesses: chart review, poor methodology, not ED pts – hard to know what type of screening they’d undergone prior to admission to this department. Just because they’re potentially reversible doesn’t mean they will be

Clinical bottom line: in this study 20-30% of folk (both new and established diagnosis) had a potentially reversible cause the commonest being depressive pseudodementia, B12 deficiency, normal pressure hydrocephalus

References/Kudos: 

• Billy Mallon on EMA. The essay is on medium

Paper Chosen by: Dave McCreary

Clinical Question: To test the effectiveness of smooth muscle relaxant drugs in assisting passage of ureteric calculi

1st Author: Robert Pickard

Journal: Lancet 2015

PMID: 25998582

Title: Medical Expulsive Therapy in Adults with Ureteric Colic: a multicentre, randomised, placebo controlled trial

Patients studied:

• Included: Adults ages 18-65 with confirmed ureteric stones 10mm or less.
• Excluded: Need for immediate intervention / sepsis / eGFR <30 / already on alpha or Ca Ch blocker

Intervention: Tamsulosin 400mcg OD or Nifedipine 30mg OD, or Placebo OD

Comparison: Tamsulosin/Nifedipine vs Placebo & Tamsulosin vs Nifedipine

Outcomes:

• Primary: Rate of spontaneous stone passage at 4/52 (defined as no intervention planned in that period) – no difference found, including subgroup analysis for sex / stone size / location
• Secondary: Daily analgesic use / Time to stone passage / Health status – no difference found

Strengths: Well thought out, pragmatic study. Exceeded sample size from power calculation (for primary outcome follow up). Population relevant to ED. Subgroup analysis to include stones 5-10 mm and all regions of the ureter.

Weaknesses: Patients all had to have CTKUB proven stone so male > female (likely due to radiation concerns) Doesn’t state whether recruitment was from ED / OPD / Ward. Was 4/52 follow up for primary outcome long enough?

Clinical bottom line:

• This is currently the best evidence available and does not support the routine use of medical expulsive therapy for patients being managed conservatively for symptomatic ureteric calculi.
• There may have been a slight trend to benefit in tamsulosin for larger (>5mm), more distal stones, but in this study didn’t reach statistical significance.

References/Kudos:

• EM Literature of Note: Finally an End to Tamsulosin for Renal Colic?
  
• EM Nerd: The Adventure of the Unpassable Stone
  
• EMDocs.net

Paper Chosen by: Andy Neill

Clinical Question: Can Sexual Intercourse Be an Alternative Therapy for Distal Ureteral Stones

1st Author: Doluoglu

Journal: Urology

PMID:  26142575

Title: Can Sexual Intercourse Be an Alternative Therapy for Distal Ureteral Stones? A Prospective, Randomized, Controlled Study

Patients studied: Men with known small (<5) stones in distal ureter. Needed an active sexual partner

Intervention: 3 groups.

• sex 3 times a week

Comparison:

• tamsulosin
• symptomatic treatment only

Outcomes: stone passage (patient report and disappearance on imaging) unclear on what timescale

Strengths: randomised, they did a power calculation but they had to infer some of it as this hadn’t been studied prior

Weaknesses: lots… unblinded, no idea about contamination (no way of determining how much sex people were having in any group and not reported). the power calculation was done on the basis that tamsulosin actually helped (which the other paper this month questions). very small sample size

Clinical bottom line: they found good early benefit at 2 weeks (80 v45 v 35% passage) all equalled out at the end. interesting idea – study not good enough to change anything

References/Kudos:

• EM Lit of Note

Paper Chosen by: Chris Connolly

Clinical Question: In patients with finger injuries, does a single volar injection provide as good analgesia as ‘ring block’ double injection technique?

1st Author: Martin

Journal: Emergency Medicine Australasia

PMID: 26991958

Title: Double-dorsal versus single-volar digital subcutaneous anaesthetic injection for finger injuries in the emergency
department: A randomised controlled trial

Patients studied: Adults presenting to ED requiring a digital nerve block,. 86 ptients randomised. intention to treat analysis. power ‘estimated’ (i think) to a 10mm difference in pain score

Intervention: Single volar SC injection of 2-3ml 1%lidocaine just distal to the mcpj crease

Comparison: standard’ double dorsal injection with 1ml each side.

Outcomes: Primary outcome measure was the pain associated with the injection, secondary outcome was pain associated with the injury 5mins post injection and success of the injection.

Strengths: power calculation done. allocation concealment undertaken. intention to treat analysis undertaken.

Weaknesses: no attempt to blind the pain assessor to the technique performed. more likely beneficial or useful to know if the injection is as successful or even better than single site injection. 

Clinical bottom line: There’s no difference in pain form injection of single site injection for finger injuries, this was not powered to detect a difference in injury associated pain scores.

References/Kudos:

• Lauren Westafer on LITFL R&R 127