Kaouthar Beltaief

Prediction value of the Canadian CT head rule and the New Orleans criteria for positive head CT scan and acute neurosurgical procedures in minor head trauma: a multicenter external validation study.

STUDY OBJECTIVE The New Orleans Criteria and the Canadian CT Head Rule have been developed to decrease the number of normal computed tomography (CT) results in mild head injury. We compare the performance of both decision rules for identifying patients with intracranial traumatic lesions and those who require an urgent neurosurgical intervention after mild head injury. METHODS This was an observational cohort study performed between 2008 and 2011 on patients with mild head injury who were aged 10 years or older. We collected prospectively clinical head CT scan findings and outcome. Primary outcome was need for neurosurgical intervention, defined as either death or craniotomy, or the need of intubation within 15 days of the traumatic event. Secondary outcome was the presence of traumatic lesions on head CT scan. New Orleans Criteria and Canadian CT Head Rule decision rules were compared by using sensitivity specifications and positive and negative predictive value. RESULTS We enrolled 1,582 patients. Neurosurgical intervention was performed in 34 patients (2.1%) and positive CT findings were demonstrated in 218 patients (13.8%). Sensitivity and specificity for need for neurosurgical intervention were 100% (95% confidence interval [CI] 90% to 100%) and 60% (95% CI 44% to 76%) for the Canadian CT Head Rule and 82% (95% CI 69% to 95%) and 26% (95% CI 24% to 28%) for the New Orleans Criteria. Negative predictive values for the above-mentioned clinical decision rules were 100% and 99% and positive values were 5% and 2%, respectively, for the Canadian CT Head Rule and New Orleans Criteria. Sensitivity and specificity for clinical significant head CT findings were 95% (95% CI 92% to 98%) and 65% (95% CI 62% to 68%) for the Canadian CT Head Rule and 86% (95% CI 81% to 91%) and 28% (95% CI 26% to 30%) for the New Orleans Criteria. A similar trend of results was found in the subgroup of patients with a Glasgow Coma Scale score of 15. CONCLUSION For patients with mild head injury, the Canadian CT Head Rule had higher sensitivity than the New Orleans Criteria, with higher negative predictive value. The question of whether the use of the Canadian CT Head Rule would have a greater influence on head CT scan reduction requires confirmation in real clinical practice.

Acupuncture vs intravenous morphine in the management of acute pain in the ED

BACKGROUND Acupuncture is one of the oldest techniques to treat pain and is commonly used for a large number of indications. However, there is no sufficient evidence to support its application in acute medical settings. METHODS This was a prospective, randomized trial of acupuncture vs morphine to treat ED patients with acute onset moderate to severe pain. Primary outcome consists of the degree of pain relief with significant pain reduction defined as a pain score reduction ≥50% of its initial value. We also analyzed the pain reduction time and the occurrence of short-term adverse effects. We included in the protocol 300 patients with acute pain: 150 in each group. RESULTS Success rate was significantly different between the 2 groups (92% in the acupuncture group vs 78% in the morphine group P<.001). Resolution time was 16±8 minutes in the acupuncture group vs 28±14 minutes in the morphine group (P<.005). Overall, 89 patients (29.6%) experienced minor adverse effects: 85 (56.6%) in morphine group and 4 (2.6%) in acupuncture group (P<.001). No major adverse effects were recorded during the study protocol. In patients with acute pain presenting to the ED, acupuncture was associated with more effective and faster analgesia with better tolerance. CONCLUSION This article provides an update on one of the oldest pain relief techniques (acupuncture) that could find a central place in the management of acute care settings. This should be considered especially in todays increasingly complicated and polymedicated patients to avoid adverse drug reactions.

Acute coronary syndrome among patients with chest pain: Prevalence, incidence and risk factors

BACKGROUND Urbanization and adoption of new diet and lifestyles had increased the cardiovascular risk factor (CVRF) rate and therefore, acute coronary syndrome (ACS) in developing countries such as Tunisia. We aimed at determining ACS prevalence among a sample of Tunisian patients with chest pain, at establishing the standardized incidence rate (SIR) of ACS, and at quantifying the relationship between ASC and CVRF in this population. METHODS We studied 3158 patients admitted to a chest pain unit for non-traumatic chest pain collected in Emergency Data from January 2012 to December 2014. For all patients, the data were collected using a standardized form. We performed univariate rather than multivariate logistic regression analyses to identify age and gender-related CVRF in ACS. Linear interpolation was used for curve estimation. RESULTS 707 (22.3%) chest pain patients were classified as ACS. The age-SIR per 10(-5)personyear (PY) was 85.7; it was 112.6 in men and 45.3 in women. Eighty one percent of patient with ACS cumulated 2 CVRF and more. The highest odds ratio were 2.00 (95% CI 1.64-2.44) for diabetes and 1.81 (95% CI 1.50-2.18) for active smoking. ACS in elderly patients was significantly associated with active smoking (OR: 2.36), diabetes (OR: 1.72) and personal ACS history (OR: 1.71). We found a significant and very high linear relation between the number of CVRF and ACS odds ratio (R(2)=0.958). CONCLUSION Our results showed that the incidence of ACS in a Tunisian population is not very different from what is observed in developed countries; with a close relation with CVRF especially diabetes and smoking.

Efficacy and safety of nebulized morphine given at 2 different doses compared to IV titrated morphine in trauma pain.

BACKGROUND Our aim was to compare the efficacy and safety of intravenous (IV) titrated morphine with nebulized morphine given at 2 different doses in severe traumatic pain. METHODS In a prospective, randomized, controlled double-blind study, we included 300 patients with severe traumatic pain. They were assigned to 3 groups: Neb10 group received 1 nebulization of 10-mg morphine; Neb20 group received 1 nebulization of 20-mg morphine, repeated every 10 minutes with a maximum of 3 nebulizations; and the IV morphine group received 2-mg IV morphine repeated every 5 minutes until pain relief. Visual analog scale was monitored at baseline, 5, 10, 15, 20, 25, 30, and 60 minutes after the start of drug administration. Treatment success was defined by the percentage of patients in whom visual analog scale decreased greater than or equal to 50% of its baseline value. When this end point was not reached, rescue morphine was administered. Pain resolution time was defined by the elapsed time between the start of the protocol and the reach of treatment success criteria. RESULTS Success rate was significantly better at 97% (95% confidence interval [CI], 93-100) for Neb20 group compared to Neb10 group (81% [95% CI, 73-89]) and IV morphine group (79% [95% CI, 67-84]). The lowest resolution time was observed in Neb20 group (20 minutes [95% CI, 18-21]). Side effects were minor and significantly lower in both nebulization groups compared to IV morphine group. CONCLUSIONS Nebulized morphine using boluses of 10 mg has similar efficacy and better safety than IV titrated morphine in patients with severe posttraumatic pain. Increasing nebulized boluses to 20 mg increases the effectiveness without increasing side effects.

Effect on morphine requirement of early administration of oral acetaminophen versus acetaminophen/tramadol combination in acute pain

To evaluate the effect on opioid requirement of pain treatment starting at triage, and to evaluate satisfaction in emergency department (ED) patients with acute pain.

Effects of Ramadan fasting on aspirin resistance in type 2 diabetic patients

Aims Ramadan fasting (RF) may affect aspirin resistance. We conducted this study in patients with cardiovascular risk (CVR) factors to assess the effect of RF on aspirin resistance and explore whether type 2 diabetes mellitus (DM) would influence this effect. Methods A total of 177 stable patients with ≥2 CVR factors were recruited. All patients observed RF and were taking aspirin. Physical exam and standard biological tests including glycaemia and serum lipids data were performed before Ramadan (Pre-R), at the last week of Ramadan (R) and four weeks after the end of Ramadan (Post-R). In the same visits caloric intake was calculated and platelet reactivity to aspirin was assessed using Verify Now point-of-care assay. Results In the overall population, there was no significant change in absolute aspirin reaction unit (ARU) values and in metabolic parameters. In DM patients (n = 127), ARU change from Pre-R values was+19.7 (p = 0.01) and +14.4 (p = 0.02) respectively at R and Post-R. During Ramadan, glycaemia, triglycerides, and cholesterol levels increased significantly and returned to Pre-R values thereafter. These changes were not observed in non-DM patients. Conclusions During RF aspirin resistance increased only in DM patients. This effect persisted one month after Ramadan. Simultaneous alteration of glycemic control and increase of serum lipids levels could potentially be a favorable factor. Study registration The protocol was registered at clinicaltrials.gov under: NCT02720133.

Acupuncture versus titrated morphine in acute renal colic: a randomized controlled trial

Objective The objective of this study was to compare the analgesic effect and tolerance profile of acupuncture versus intravenous (IV) titrated morphine in patients presenting to the emergency department (ED) with renal colic. Materials and methods A total of 115 patients were randomized into two groups. Patients in the IV titrated-morphine group (n=61) received 0.1 mg/kg morphine every 5 minutes until pain score dropped by at least 50% of its baseline value. Patients in the acupuncture group (n=54) received an acupuncture session of 30 minutes following a prespecified protocol. The visual analog scale (VAS) was used to assess pain intensity at baseline and at 10, 20, 30, 45, and 60 minutes following the start of the treatment protocol. Possible treatment side effects were also recorded. Results No significant differences were found between the two groups concerning age, sex, or baseline VAS score. From the 10th minute until the end of the intervention, acupuncture was associated with a deeper analgesic effect than titrated morphine (P<0.05 from the 10th minute and over). Analgesia was also faster in the acupuncture group, with time to obtain 50% reduction of baseline VAS of 14 minutes in the acupuncture group versus 28 minutes in the IV titrated-morphine group (P<0.001). Only three patients in the acupuncture group experienced minor side effects versus 42 in the morphine group (P<0.001). No major side effects were observed in this study. Conclusion In ED patients with renal colic, acupuncture was associated with a much faster and deeper analgesic effect and a better tolerance profile in comparison with titrated IV morphine.

Nebulized Terbutaline and Ipratropium Bromide Versus Terbutaline Alone in Acute Exacerbation of Chronic Obstructive Pulmonary Disease Requiring Noninvasive Ventilation: A Randomized Double‐blind Controlled Trial

BACKGROUND Short-acting β2 -agonists are the mainstay of treatment of patients with acute exacerbation of chronic obstructive pulmonary disease (AECOPD) in the emergency department (ED). It is still unclear whether the addition of short-acting anticholinergics is clinically more effective care compared to treatment with β2 -agonists alone in patients with hypercapnic AECOPD. OBJECTIVE The objective was to evaluate whether combining ipratropium bromide (IB) to terbutaline reduces hospital and intensive care unit (ICU) admission rates compared to terbutaline alone in AECOPD hypercapnic patients. METHODS In this double-blind controlled trial, patients who were admitted to the ED for AECOPD requiring noninvasive ventilation (NIV) were randomized to receive either 5 mg of nebulized terbutaline combined to 0.5 mg of IB (terbutaline/IB group, n = 115) or 5 mg of terbutaline sulfate (terbutaline group, n = 117). Nebulization was repeated every 20 minutes for the first hour and every 4 hours within the first day. Primary outcomes were the rate of hospital admission and need for endotracheal intubation within the first 24 hours of the start of the experimental treatment. Secondary outcomes included changes from baseline of dyspnea, physiologic variables, length of hospital stay, ICU admission rate, and 7-day mortality. RESULTS The two groups were similar regarding baseline demographic and clinical characteristics. Hospital admission was observed in 70 patients (59.8%) in the terbutaline/IB group and in 75 patients (65.2%) in the terbutaline group (respiratory rate [RR] = 1.09, 95% confidence interval [CI] = 0.93 to 1.27, p = 0.39). ICU admission was required in 37 (32.2%) patients in the terbutaline/IB group and 30 patients (25.6%) in terbutaline group (RR = 1.25, 95% CI = 1.02 to 1.54, p = 0.27). There were no significant differences in dyspnea score, blood gas parameters changes, vital signs improvement, and 7-day death rate between both groups. CONCLUSION In patients admitted to the ED for AECOPD requiring NIV, combination of nebulized IB and terbutaline did not reduce hospital admission and need to ICU care.

One-Year Outcome of Intensive Insulin Therapy Combined to Glucose-Insulin-Potassium in Acute Coronary Syndrome: A Randomized Controlled Study.

Background A number of factors may offset the cardioprotective effects of glucose‐insulin‐potassium (GIK) on outcome of patients with acute coronary syndrome, such as hyperglycemia induced by this cocktail infusion. We performed a study to evaluate the effect of intensive insulin therapy in association with GIK on 1‐year outcome in patients hospitalized for acute coronary syndrome. Methods and Results In a randomized prospective controlled trial we included 772 patients with non–ST‐segment elevation acute coronary syndrome. Patients were randomized into 3 groups: GIKI2 group, who received GIK with intensive insulin therapy for 24 hours; GIK group, who received GIK with nonintensive insulin therapy; and control group, who received usual care. The primary outcome criteria were the rates of major cardiovascular events combining death, reinfarction, and stroke rate at 1 year. In addition, we measured platelet function assay‐100 and plasminogen activator inhibitor‐1 at admission and 24 hours later. Based on an intention‐to‐treat analysis, major cardiovascular events at 1 year was 12.8% in the GIKI2 group, 15.5% in the GIK group, and 20.5% in the placebo group; the difference was significant between the GIK2 and control groups (P=0.01). Platelet function assay‐100 at 24 hours decreased significantly from baseline in the control group but not in the GIKI2 group. Plasminogen activator inhibitor‐1 decreased significantly in the GIKI2 group but significantly increased in the control group. Minor hypoglycemic events were more frequent in the GIKI2 group compared with other groups. Conclusions GIKI2 led to improvement of 1‐year outcome rates in patients with non–ST‐segment elevation acute coronary syndrome. This beneficial effect was associated with a decrease in platelet reactivity and an increase on fibrinolysis tests. Clinical Trial Registration URL: https://www.clinicaltrials.gov. Unique identifier: NCT00965406.

Value of Plethysmographic Pulse Amplitude Ratio With Valsalva Maneuver in Identifying Left Ventricular Dysfunction During COPD Exacerbation

BACKGROUND: Left-ventricular dysfunction associated with COPD exacerbation is frequently underestimated. We tested whether finger plethysmography waveform change during the Valsalva maneuver could aid in the distinction between patients with COPD exacerbation with and without left-ventricular dysfunction. METHODS: We included 102 subjects with COPD exacerbation and 51 subjects with acute heart failure admitted to the emergency department for acute dyspnea. Measurements of the plethysmographic pulse amplitude ratio under the Valsalva maneuver were obtained. The value of the plethysmographic pulse amplitude ratio in diagnosing left-ventricular dysfunction in COPD exacerbation subjects was quantified using the area under the receiver operating characteristic curves. Diagnostic performance of the plethysmographic pulse amplitude ratio was compared with the Boston score, and the net reclassification improvement was calculated to determine the incremental value in detecting left-ventricular dysfunction. RESULTS: Values of the plethysmographic pulse amplitude ratio were higher in COPD exacerbation subjects with left-ventricular dysfunction compared with those without left-ventricular dysfunction (0.78 vs 0.38, P = .01) but not significantly different from those of the acute heart failure group (0.78). There was a significant correlation between plethysmographic pulse amplitude ratio values and brain natriuretic peptide serum levels. The area under the receiver operating characteristic curve for the plethysmographic pulse amplitude ratio to detect left-ventricular dysfunction among subjects with COPD exacerbation was significantly higher compared with that of the Boston score (0.92 vs 0.76, P = .02). Exposure to plethysmographic pulse amplitude ratio values increased the overall accuracy from Boston score-based predictions of left-ventricular dysfunction and provided a net reclassification improvement of 17.3%. CONCLUSIONS: An increased plethysmographic pulse amplitude ratio associated with COPD exacerbation is a good predictor of left-ventricular dysfunction. This simple and noninvasive index could help emergency department physicians to detect or rule out left-ventricular dysfunction in patients with COPD exacerbation who are able to perform the Valsalva maneuver. (ClinicalTrials.gov registration NCT01619540.)