Sunday 21 February 2021

Compression Therapy to Prevent Recurrent Cellulitis of the Leg… way to go Bruce!

We’ve all seen them…

Those big red chronic oedematous legs that we diagnose as cellulitis. We start IV antibiotics and admit. But those same legs come back to the ED again and again…

Hummm... should we be doing something to prevent recurrent cellulitis in oedematous legs?

These investigators from the Public Hospital Bruce, Canberra, conducted a single centre non-blinded RCT of patients with chronic oedema of the leg and recurrent cellulitis. Participants were randomised to leg compression therapy vs. control.

The primary outcome was recurrence of cellulitis as diagnosed by GP’s or hospital physicians and confirmed by trial assessors. There were a bunch of secondary outcomes including measuring leg volume with the use of a perometer (huh?), quality of life, adherence to intervention etc.

Shortly after starting the trial, lymphoedema therapists who were aware of the group assignments noticed a potential large treatment effect and brought it to the attention of the Human Research Ethics Committee (HREC). Stopping rules were added to the study protocol. As expected, the trial was stopped early for efficacy.

In the end, 84 patients were enrolled with 23 episodes of recurrent cellulitis. There were 6 (15%) patients with cellulitis in the compression group and 17 (40%) in the control arm.

Wow… an absolute reduction of 25% or NNT of 4. This is crazy efficacy.

(Just in case you were curious, the perometer showed a between group difference of -240ml in leg volume over time.)

Critics of this trial could justifiably point out that it was really small, stopped early, and conducted at single centre.  But perhaps the biggest limitation was the diagnosis of recurrent cellulitis is subjective and it was adjudicated by those who were unblinded- potentially leading to bias.

Either way, these results are very compelling, in line with expert opinion and should be practice changing. As ED doctors, we don’t usually focus on preventative medicine. But this intervention will have much more effect than those countless tetanus immunisations we give away.

Looks like it’s time to get on the compression train.


Compression Therapy to Prevent Recurrent Cellulitis of the Leg. N Engl J Med. 2020;383:630-9. [link to article]

Saturday 20 February 2021

Short-Term Topical Tetracaine is Highly Efficacious for the Treatment of Pain Caused by Corneal Abrasions: A double-blind RCT

It seems to me that these researchers asked the wrong question. Most of us know that numbing up a corneal abrasion relieves pain. But the big question has always been is it safe to send patients home with topical anaesthetic. For decades, ophthalmologist have been telling us it is dangerous.  But lately, this dogma has been challenged with better quality research.

So if they didn't ask the right questions, then why was this study conducted and published in our peak emergency medicine journal?

It turns out we have never proven the efficacy of topical anaesthetics for outpatient treatment of simple corneal abrasions with an RCT. Go figure...

But, now we have.

This well conducted RCT out of a single ED in Oklahoma (yeeeehaaaaaaa!) randomised 111 patients to 2ml’s of tetracaine drops vs placebo to take home. The primary outcome was the overall NRS pain score at a 24-hour and 48-hour ED follow-up.

As expected, the tetracaine worked marvellously. Pain score was 1/10 in the tetracaine group and 8/10 in the placebo group. This is a huge difference with lots of pretty p values. The placebo group also gulped down more Vicodin than the those given tetracaine (don’t get me started…)

Unfortunately, we cannot make claims about safety with so few trial participants. A much larger study will be needed to find less common side effects. But the original studies that suggested harm are old and poor quality. It seems that the current best evidence suggests topical anaesthetics are probably safe and definitely effective for simple corneal abrasions.

But don’t be surprised if your local ophthalmologists disagree… it's hard to teach an old dog(ma) new tricks. 



Shipman S, Painter K, Keuchel M, et al. Short-Term Tetracaine is Highly Efficacious for the Treatment of Pain Caused by Corneal Abrasions: A Double-Blind, Randomized Clinical Trial. Ann Emerg Med. 2020 Oct 27;S0196-0644(20)30739-3.    doi: 10.1016/j.annemergmed.2020.08.036 [link to article]



Thursday 18 February 2021

Early Rhythm-Control Therapy in Patients with Atrial Fibrillation

Rate vs. rhythm control of atrial fibrillation has been a perennial question.

These investigators sough to determine if patients with “early atrial fibrillation” (<1 year since diagnosis) and cardiovascular conditions had better outcomes with rhythm control.

The was a behemoth study and worthy of publication in the NEJM.

2789 patients in 135 centres in 11 different countries in Europe were randomised to either rhythm control (antiarrhythmic drugs, ablation, & cardioversion) vs. usual care (mostly rate control but occasionally rhythm control to manage AF related symptoms.)

One primary outcome was a composite of death from cardiovascular cause, hospitalisation for heart failure and/or ACS. The other primary outcome was nights spent in hospital. There were lots of secondary and safety outcomes.

After a median 5 year per patient follow up time, the trial was stopped early due to efficacy at the 3rd interim analysis. There was an absolute decrease of 1.1 events per 100 person years for the first primary outcome. This may not seem like much of a treatment effect, but there are a lot of people out there with AF.

No study is perfect, and this one has some limitations. There were reasonably narrow inclusion criteria which limit generalisability. It probably excluded most symptomatic patients as they would not have been candidates to be randomised to “usual care.” In the manuscript, there is an entire column of author conflicts of interest- in small font no less! Cardiologist love to cosy up to industry….

Either way, this study will change the guidelines. And in speaking with my local electrophysiologist, this study has already changed practice. Cardiologists are pushing suitable patients with new AF towards a rhythm control strategy with antiarrhythmics and more ablations are being performed.

Of course, emergency physicians are not likely to prescribe antiarrhymics and certainly won’t do ablations (unless you want a friendly visit from a regulatory body). But it is good for us to know the overall strategy and we will be asked to be more aggressive with early rhythm control.


Kirchhof P, Camm AJ, Goette A, et al. Early Rhythm-Control Therapy in Patients with Atrial Fibrillation. N Engl J Med. 2020;383:1305-16. [link to article]

Testicular Workup for Ischemia and Suspected Torsion in Pediatric Patients and Resource Utilisation: Everybody do the TWIST?


The TWIST score is a "validated" clinical decision instrument to aid in the diagnosis of acute testicular torsion.

TWIST sore?

Yes, I’ve never heard of it either… and I will probably forget about it very soon.

The TWIST score (0-7) is calculated by the presence of testicular swelling (2 points), hard testes (2 points), nausea/vomiting (1 point), high riding testes (1 point), and absent cremasteric reflex (1 point). Based on the score, patients can be stratified into high, intermediate, or low risk. I’ll spare you further details…

These authors sought to apply the TWIST score to a group of patients by performing a retrospective medical record review. They were looking at potentially decreasing formal ultrasound use, decreasing ED length of stay and ischemic time. (Methods for their chart review are absent however…)


77 patients were identified by ICD-10 codes. All 9 high risk patients had torsion. And it was absent in the 57 low risk patients. The authors claim the score could have reduced the need for ultrasound 75% of the time and reduced ischemia time.

Sounds great, but there are major problems with this study.

Retrospectively collected data is usually poor quality. The authors assumed data not recorded indicated absence of findings. Of course, this is nuts (sorry).

Regardless of prior studies, I don’t believe the TWIST score has face validity. The most important features in diagnosis of torsion are the appropriate age (usually adolescent) and the history. Sudden severe pain with vomiting and potentially a high-riding testicle is all you need. These patients should not be getting ultrasounds… just an immediate referral to the appropriate surgeon. A hard & swollen testicle is very common in orchitis and I can’t believe it wound be discriminatory. 

Of course, a clinical decision instrument should improve upon what we do already. These scores must be compared to clinician gestalt before being adopted. Otherwise we don’t know if they will underperform and cause harm.

Regardless of what Cubby Checker says, please don’t do the TWIST.



Roberts CE, Ricks WA, Roy JD, et al. Testicular Workup for Ischemia and Suspected Torsion in Pediatric Patients and Resourse Utilization. J Surg Res. 2021;257:406-411. [link to article]