Welcome back to our update on the latest literature in EM.
Paper Number 1
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
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.
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:
- WBCT when done indicriminately likely artifically increases ISS score making people look sicker than maybe they are
- WBCT most likely to be of benefit in severely injured patients but not in others
- WBCT shouldn’t be used as a substitute for hx/clinical examination
- REACT 2 is coming (RCT)
Paper Number 2
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
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
- Billy Mallon on EMA. The essay is on medium
Paper Number 3
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
Title: Medical Expulsive Therapy in Adults with Ureteric Colic: a multicentre, randomised, placebo controlled trial
- 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
- 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.
- EM Literature of Note: Finally an End to Tamsulosin for Renal Colic?
- EM Nerd: The Adventure of the Unpassable Stone
Paper Number 4
Paper Chosen by: Andy Neill
Clinical Question: Can Sexual Intercourse Be an Alternative Therapy for Distal Ureteral Stones
1st Author: Doluoglu
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
- 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
Paper Number 5
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
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.