Jill Corbo

A trial of metoclopramide vs sumatriptan for the emergency department treatment of migraines

Objective: To compare the efficacy of 20 mg of IV metoclopramide, given up to four times over 2 hours as needed for persistent headache, with 6 mg of subcutaneous sumatriptan for the emergency department treatment of migraine headaches. Methods: This was a randomized, double-blind, clinical trial with two intervention arms. The primary endpoint was change in pain intensity as measured by an 11-point pain scale at 2 hours. Secondary endpoints included change in pain intensity at 24 hours and rates of pain-free headache relief at 2 and 24 hours. Results: Two hundred two patients were screened, and 78 of 91 eligible patients were randomized. The two groups had comparable pain scores at baseline. By 2 hours, the change in pain intensity for the metoclopramide group was 7.2 compared with 6.3 for the sumatriptan group (95% CI for difference: −0.2 to 2.2). When compared at 24 hours, the metoclopramide group had improved by 6.1 compared with baseline and the sumatriptan group had improved by 5.0 (95% CI for difference: −0.6 to 2.8). At 2 hours, pain-free rates were 59% in the metoclopramide arm and 35% in the sumatriptan arm (95% CI for difference of 24%: 2 to 46%). The most common side effects at both time points were weakness, dizziness, and drowsiness, which were distributed evenly between the two groups. There were no reports of chest pain within the first 2 hours. The incidence of restlessness, stiffness, and abnormal movements was distributed equally between the two groups. Conclusions: When compared at 2 and 24 hours, aggressive (20 mg dosed up to four times) IV metoclopramide and 6 mg of subcutaneous sumatriptan relieved migraine headache pain comparably. Some secondary endpoints suggest that metoclopramide may be the preferable therapy for migraines presenting to the emergency department.

A clinical trial of trimethobenzamide/diphenhydramine versus sumatriptan for acute migraines.

Background.—Although various classes of medication are used to treat acute migraine in the emergency department (ED), no treatment offers complete pain relief without side effects or recurrence of headache. Consequently, even though several antiemetic medications as well as SQ sumatriptan have demonstrated efficacy and tolerability for the ED treatment of migraine, there remains a need for more effective parenteral therapies. Open‐label studies suggest that the combination of trimethobenzamide and diphenhydramine (TMB/DPH) may provide effective relief in a high proportion of migraineurs.

External Validation of the STONE Score, a Clinical Prediction Rule for Ureteral Stone: An Observational Multi-institutional Study

Study objective The STONE score is a clinical decision rule that classifies patients with suspected nephrolithiasis into low-, moderate-, and high-score groups, with corresponding probabilities of ureteral stone. We evaluate the STONE score in a multi-institutional cohort compared with physician gestalt and hypothesize that it has a sufficiently high specificity to allow clinicians to defer computed tomography (CT) scan in patients with suspected nephrolithiasis. Methods We assessed the STONE score with data from a randomized trial for participants with suspected nephrolithiasis who enrolled at 9 emergency departments between October 2011 and February 2013. In accordance with STONE predictors, we categorized participants into low-, moderate-, or high-score groups. We determined the performance of the STONE score and physician gestalt for ureteral stone. Results Eight hundred forty-five participants were included for analysis; 331 (39%) had a ureteral stone. The global performance of the STONE score was superior to physician gestalt (area under the receiver operating characteristic curve=0.78 [95% confidence interval {CI} 0.74 to 0.81] versus 0.68 [95% CI 0.64 to 0.71]). The prevalence of ureteral stone on CT scan ranged from 14% (95% CI 9% to 19%) to 73% (95% CI 67% to 78%) in the low-, moderate-, and high-score groups. The sensitivity and specificity of a high score were 53% (95% CI 48% to 59%) and 87% (95% CI 84% to 90%), respectively. Conclusion The STONE score can successfully aggregate patients into low-, medium-, and high-risk groups and predicts ureteral stone with a higher specificity than physician gestalt. However, in its present form, the STONE score lacks sufficient accuracy to allow clinicians to defer CT scan for suspected ureteral stone.

PD4-03 A RANDOMIZED TRIAL OF ULTRASOUND VERSUS COMPUTED TOMOGRAPHY FOR IMAGING PATIENTS WITH SUSPECTED NEPHROLITHIASIS

INTRODUCTION AND OBJECTIVES: We present the first application of a percutaneous navigation system (Translucent Medical, Inc.) which integrates GPS technology with a movable tablet display of virtual 3D models. Both the surgical tools and the movable tablet display are trackedbyGPStechnologyanddigitallyalignedwitheachother. In realtime, this system displays the internal anatomy, superimposed surgical tools, and navigation aids (such as predicted puncture line). The objective of our study was to assess the feasibility and accuracy of this system in a cadaver model for targeted interventions of the prostate and kidney. METHODS: Gold fiducial-markers (CIVCO Medical), which served as target center of the virtual tumor (Target-fiducial), were needle-implanted in kidney and prostate parenchyma. Then a preoperative CT scan was obtained, and CT-DICOM data were transferred to the system to construct 3D surgical models. A needle, with built-in GPS sensors, was used as the therapeutic puncture needle. When the system indicated coincidence of the needle-tip and target-fiducial, another gold fiducial (Treatment-fiducial) was placed through the outersheath of the therapeutic needle. A post-operative CT was acquired to measure distance between the Target and Treatment fiducials. For each Target-fiducial, two placements of a Treatment-fiducial were attempted (from two different skin incisions >2 cm apart). RESULTS: Real-time display of the needle puncture trajectory superimposed on the 3D model allowed successful navigation in all procedures. Navigation was further enhanced by color-coded changes to the needle-icon, which indicated whether or not the current trajectory was on-track to intersect the surgical target. Median time to target was 43 sec. Mean distance from needle-tip to target was 2.5mm (as calculated by the tracking system). Distance between the Targetand Treatment-fiducial was 16.6 mm in the prostate and 12 mm in the kidney. Distance between the paired Treatment-fiducials was 7.7mm. Analyzing each axial component, errors were significantly greater along z-axis (p<0.01), likely due to the intra-operative compression of the organ during puncture, resulting in possible rotation, shift, or deformation of the soft-tissue cadaveric organ. CONCLUSIONS: This virtual navigation system, integrating GPS-technology with movable tablet display, is promising for percutaneous interventions. In order to minimize possible errors, further work is needed to augment the tracking system for intra-corporeal organ motion/deformation.