Tuesday, 23 November 2021

Dexamethasone in hospitalized patients with COVID-19


Prior to the publication of this study, there was quite a lot of debate about the efficacy of dexamethasone for hospitalized patients with COVID. 

But not now…

The RECOVERY trial was designed to quickly look at many potential treatments for COVID. A whopping 176 NHS organizations in the UK were involved and with no shortage of patients to enroll.

Hospitalized patients with COVID were randomized to get either 6mg of dexamethasone daily for 10 days or usual care alone.

Primary outcome was all cause mortality at 28 days. There were lots of prespecified secondary outcomes.

6425 patients were recruited from March to June 2020. Overall, 22.9% of patients in the dexamethasone group died vs. 25.7% in the usual care arm. Absolute difference of 2.8% for a number needed to treat (NNT) of 36.

But the benefit seemed to be best in the sickest patients that were ventilated; NNT 8. There was a trend towards harm in the healthier group not requiring oxygen.

There are some limitations to this study, the biggest being our care of COVID has changed since it was conducted, care was not standardized, and this was an unvaccinated cohort. Nevertheless, it was generally well performed and (for now) it is considered practice changing.

Dexamethasone is no “magic bullet” but another piece of the puzzle that might provide some benefit to those sick enough to be hospitalized with COVID. However, no therapies have come even close to the benefits we see with vaccination.

Get ‘em all vaccinated!

 

Covering:

The RECOVERY Collaborative Group, Dexamethasone in Hospitalized Patients with COVID-19. N Engl J Med 2021;384:693-704. [link to full text article]

 

 

 

Tuesday, 19 October 2021

MRI of cervical spine in trauma: A retrospective single-centre audit of patient outcomes


In patients with a normal cervical spine CT but persistent tenderness or neurology, how often is a subsequent MRI abnormal? And what happens afterwards? Here's an answer from Gelong...

(Spoiler alert... the real question should be, "does MRI find occult injury that results in genuine improvements in patient-oriented outcomes? Or does it cause harm from overdiagnosis?")

These authors from a single centre, looked retrospectively at a cohort of trauma patients that had both a negative cervical spine CT and a subsequent MRI. (Adult patients had to be alert and <72 hours between the studies.)

Results?

228 patients were included.

Of the 181 patients that had the MRI for persistent tenderness, 35 (20% or one-in-five) had an abnormal MRI. Of those, 14 were treated with a rigid collar and no patients underwent surgery.

Of the 47 patients that had the MRI for neurological findings, 11 (23%) had an abnormal MRI. Four patients were managed with collars. Two patients required surgery and the manuscript described their presentation & hospital course. Their neurologic issues were not subtle.

The authors appropriately conclude that the MRI is of “questionable” utility in those without neurology.

But could the MRI be even worse? Could it identify injuries that would heal just fine had we never found them only to subject patients to weeks of unnecessary immobilisation, discomfort, and potential harm? Unfortunately, this was not really addressed in this study.

With technology advances, MRI will only get more sensitive at finding “abnormalities." In addition, MRI will become more readily available. We need to have some serious discussions; just because we can, should we? 

 

Covering:

Foster G, Russel B, Hibble B, et al. Magnetic resonance imaging cervical spine in trauma: A retrospective single-centre audit of patient outcomes. Emerg Med Aus. 2021 Sep 3.doi: 10.1111/1742-6723.13842. [link to article]

Sunday, 17 October 2021

The effectiveness of intradermal sterile water injection for low back pain in the ED: A prospective, randomized controlled trial


Intradermal water injection to alleviate low back pain?

Believe it or not, water injection has been around for many years, especially in the delivery suite. There are some proposed mechanisms as to why or how it might work.

But can water injection work in the Emergency Department?

These authors from a single center in Turkey, randomized low back pain patients who all got IV NSAIDS to either intradermal water injection or nothing else.

Inclusion criteria were adults 18-65 years old with a VAS pain score of >4. They excluded trauma, chronic back pain, those that had pain medications prior to arrival, diabetes, or BMI >30.

Outcomes were reduction of pain at 10, 20, 30 minutes and 24 hours. They also looked at patient satisfaction, need for rescue medication, etc.

Results?

112 patients enrolled and the water worked FANTASTIC! Everything they could measure was better.

Hallelujah… we have a miracle!

Unfortunately, there are some serious problems with this study.

The manuscript is awful and serves as a red flag as to the professionalism and conduct of these researchers. I would have genuinely believed that they used Google Translate and submitted a draft without changes. But there are words in the manuscript that don’t even exist on Google!

Regardless of the sloppy manuscript, there are serious methodological issues that likely render the conclusions invalid.

It was not blinded.

Of course, patients were not blinded, but nor were the clinicians in the study who also collected the outcome measures. This could have resulted in substantial subject and observer bias.

And of course, there is the placebo effect…

(But to be fair to these researchers, what is the placebo for water? Or how can you perform sham water injection? I don’t know.)

In short summary, this terribly presented paper’s findings are very likely due to bias and placebo effect.

But is it unethical to use undisclosed placebo? Holy hallelujah can of worms…

 

Covering:

Tekin E, Gur A, Bayraktar M, et al. The effectiveness of intradermal sterile water injection for low back pain in the emergency department: A prospective, randomized controlled study. Am J Emerg Med 2021;42:103-109. [link to article]

Friday, 15 October 2021

Risk stratification of patients admitted to hospital with covid-19- the 4C Mortality Score


This group of researchers from the UK sought to develop and validate a pragmatic risk score to predict mortality in patients admitted to hospital with COVID.

This prospective cohort study was performed at 260 hospitals in the UK in early 2020.

35,463 patients were included in the derivation phase and 22,361 in the internal validation. The mortality was about 30% of these admitted patients… yikes!

They used a complicated three stage model building process and used some regression analysis, machine learning and lots of other things probably best understood by those with a PhD in biostatistics.

In the end, they came up with 8 variables to predict mortality. They included age, sex, number of comorbidities, respiratory rate, oxygen saturations, GCS, urea, and CRP.

Although they intended for this score to be quite simple, nobody is going to memorize the components and how to add things up. Fortunately, mdcalc.com can do it for you.

The researchers also compared their score to 15 others in existence and thought theirs to be the best.

So, use this score if you like.

Some would argue that this score is already outdated. In the last year we have learned a lot more about COVID. Treatments have changed. And biggest limitation of all, most of the data was derived from an unvaccinated cohort.

Either way, this score has some utility. And it’s just like all risk stratification scores out there.

Yes… (wait for it)sicker patients do worse.

Or more specifically; sicker patients with worse manifestation of disease, who are older with more comorbid illness, have worse x-rays & blood tests, and lack of response to initial treatment do worse.

I use that score for everything. But for some reason, I can't find it on Mdcalc.

 

Covering:

Knight SR, Ho A, Pius R, et al. Risk stratification of patients admitted to hospital with covid-19 using the ISARIC WHO Clinical Characterisation Protocol: development and validation of the 4C Mortality Score. BMJ 2020;370:m3339. [Link to full text article]

Point-of-Care hip ultrasound leads to expedited results in ED patients with suspected septic arthritis


The title tells it all; if you do something yourself, it happens faster. Case closed...

But perhaps there is a little more we can learn from this paper.

These authors from beautiful Charlottesville, Virginia looked retrospectively at 62 patients who got an ultrasound for possible septic arthritis in their ED.

They compared the group that had the ultrasound done by ED doctors (POCUS) vs. those done in radiology. No surprise the POCUS group had the study done faster; about 1 hour vs. 3 hours.

They also looked at time to arthrocentesis which was also faster when performed by the ED doctor; about 3 hours vs. 10 hours.

Of course, this study was only from a single center, it was not randomized, and they had very small numbers. Only 10 arthrocentesis were performed by the ED doctors over 3 years. It can make no genuine claims about safety.

Hmmmm…

As ED doctors, we are very happy at tapping various joints. I’ve done tons of knees. And some shoulders, elbows, wrists, ankles and toes. But I’ve never aspirated a hip.

For some reason the hip has been taboo. Perhaps it is due to the less common nature and the higher incidence in the pediatric population. It's a deeper joint and more difficult to physically confirm the presence of an effusion. Furthermore, historic blind aspiration techniques were outside our realm.

This is not the first study looking at POCUS to guide hip arthrocentesis in the ED and we are now supported by a growing literature base.

EP’s are clearly owning ultrasound guided needle-based procedures. Perhaps hip arthrocentesis will eventually fall to the responsibility of the Emergency Physician. 

Hmmmm….

 

Covering:

Thom C, Ahmed A, Kongkatong M, et al. Point-of-care hip ultrasound leads to expedited results in emergency department patients with suspected septic arthritis. JACEP Open 2020;1:512-20. [link to full text article]

 

  

Thursday, 2 September 2021

Utilization of Prophylactic Antibiotics After Nasal Packing for Epistaxis


When I trained, I was told I needed to prescribe prophylactic antibiotics after I placed nasal packing. It was thought this reduced the potential for toxic shock syndrome or sinusitis. Is this recommendation evidence based?

Hmmmm…

This single ED in Manhattan retrospectively reviewed 275 cases of anterior nasal packing and determined the rates of antibiotics given and evidence of benefit.

Most patients that got non-absorbable packs (Merocel, RapidRhino) got antibiotics. Those with absorbable packs (Surgicel, Gelfoam) did not.  Although this aspect of the study is robust, it is hardly important… I just don’t care.

I want to know how many patients got benefit from antibiotics.

Out of the 275 cases, there was one episode of sinusitis in each group. Looks like it doesn’t matter?

But there is a fatal flaw.

They didn’t really look for outcomes.

Only 40% of the patients had documented follow up! In addition, this would have been poor quality retrospective data.

If you don’t look for something, you will not find it. Interesting that this study got published.

Probably the best thing to come out of this “study” is their review of the literature.  In a nutshell, there is moderate evidence to show that antibiotics are not needed after nasal packing.

Good enough for me.

 

Covering:

Hu L, Gordon SA, Swaminathan A, et al. Utilization of Prophylactic Antibiotics after Nasal Packing for Epistaxis. J Emerg Med. 2021;60:140-149. [link to article]

 

Elevated blood pressures are common in the ED, but are they important?


No.

You can stop reading now if you want…

This was an electronic medical record review of 30,278 adults treated and released from the University of Alberta ED in 2016.

They identified those that had elevated BP’s at triage and cross-referenced them with multiple data bases to see if they developed cardiovascular events by 2 years(Databases included hospital EDIS, Pyxis, Pharmaceutical Information Network, administrative data holdings, National Ambulatory Care Reporting systems, outpatient billing claims etc.)

Of the 30,278 that were treated and released, about half had elevated BP’s at triage. 70% had no prior history of hypertension and eventually about a quarter of those subsequently received a diagnosis of chronic hypertension.

After adjusting for confounders, high BP at triage was not associated with adverse cardiovascular outcomes within 2 years of the ED visit.

I’m willing to believe this is true… but there are many methodologic limitations.

Don’t be mesmerized by the huge number of patients… this does not guarantee quality. Nor do large numbers reduce bias.

I’m concerned about a potential “garbage in & garbage out” phenomenon. The veracity of this study is predicated on the quality of the information in many large databases. (For example, a large database in the USA shows the rate of virgin births at 0.5%)

There were a lot of other issues; retrospective design, residual confounding, use of triage BP’s, lack of follow up, possible non-differential misclassification, etc.

So, are elevated BP’s in the ED important?

I still say no, but not necessarily due to this study. Heck, at least hypertension is better than hypotension. 

 

Covering:

McAlister FA, Youngson E, Rowe B. Elevated Blood Pressures are Common in the Emergency Department but Are they Important? A Retrospective Cohrt Study of 30,278 Adults. Ann Emerg Med. 2021;77:425-432. [link to article]