Kaouther Beltaief

Phloroglucinol as an adjuvant analgesic to treat renal colic

PURPOSE We tested whether the addition of phloroglucinol to piroxicam could improve pain relief in patients with acute renal colic visiting the emergency department. MATERIALS AND METHODS Patients with a diagnosis of acute renal colic were prospectively randomized to receive intravenous phloroglucinol (200 mg) or placebo combined with intramuscular piroxicam (20 mg). We monitored the visual analogic scale (VAS), heart rate, arterial blood pressure, need for rescue therapy, and adverse events at different time points for 1 hour. We recorded admission requirement and new visit at 72 hours for renal colic. The primary end point was to assess pain relief at 1 hour, defined as a decrease of 50% or more as compared with the initial VAS. The secondary objectives were to compare the 2 groups for VAS at any time points, the need for rescue therapy, and the occurrence of adverse events. RESULTS Of the 309 eligible patients, 253 entered the study. A total of 126 patients received phloroglucinol and 127 patients received placebo. Pain relief at 1 hour was obtained in 89 patients (71%) receiving phloroglucinol and 89 patients (70%) receiving placebo (P = .89). There were no differences in VAS between the 2 groups at any time points. Rescue therapy was required in 37 patients (29%) receiving phloroglucinol and 38 patients (30%) receiving placebo (P = .51). Number of adverse events was similar with phloroglucinol and placebo: 20 (16%) and 16 (13%), respectively (P = .44). CONCLUSIONS There was no evidence that the addition of phloroglucinol improved the efficiency of piroxicam to relieve pain in acute renal colic.

A new score for the diagnosis of acute coronary syndrome in acute chest pain with non-diagnostic ECG and normal troponin

Background Acute coronary syndrome (ACS) represents a difficult diagnostic challenge in patients with undifferentiated chest pain. There is a need for a valid clinical score to improve diagnostic accuracy. Objectives To compare the performance of a model combining the Thrombolysis in Myocardial Infarction (TIMI) score and a score describing chest pain (ACS diagnostic score: ACSD score) with that of both scores alone in the diagnosis of ACS in ED patients with chest pain associated with a non-diagnostic ECG and normal troponin. Methods In this observational cohort study, we enrolled 809 patients admitted to a chest pain unit with normal ECG and normal troponin. They were prospectively evaluated in order to calculate TIMI score, chest pain characteristics score and ACSD score. Diagnosis of ACS was the primary outcome and defined on the basis of 2 cardiologists after reviewing the patient medical records and follow-up data. Mortality and major cardiovascular events were followed for 1 month for patients discharged directly from ED. Discriminative power of scores was evaluated by the area under the ROC curve. Results ACS was confirmed in 90 patients (11.1%). The area under the ROC curve for ACSD score was 0.85 (95% CI 0.80 to 0.90) compared with 0.74 (95% CI 0.67 to 0.81) for TIMI and 0.79 (95% CI 0.74 to 0.84) for chest pain characteristics score. A threshold value of 9 appeared to optimise sensitivity (92%) and negative predictive value (99%) without excessively compromising specificity (62%) and positive predictive value (23%). Conclusions The ACSD score showed a good discrimination performance and an excellent negative predictive value which allows safely ruling out ACS in ED patients with undifferentiated chest pain. Our findings should be validated in a larger multicentre study.

Magnesium sulfate versus ipratropium bromide in chronic obstructive pulmonary disease exacerbation: a randomized trial.

Treatment with short-acting &bgr;2-agonists for exacerbations of chronic obstructive pulmonary disease (COPD) results in clinical improvement. It has not been established whether combining short-acting &bgr;2-agonists to other bronchodilators is more effective than &bgr;2-agonists alone. We conducted a study in patients presenting to the emergency department with exacerbation of COPD. They were randomized to receive nebulized ipratropium bromide (IB group; n = 62) or combined nebulized and intravenous bolus of magnesium sulfate (MgSO4 group; n = 62). All nebulized drugs were administered at 30-minute intervals for 2 hours. Primary outcome included hospital admission, endotracheal intubation, and hospital death rates. Secondary outcome measures were improvement in peak expiratory flow, dyspnea score, and arterial blood gas changes within the first 3 hours. There were no significant differences in primary outcome between MgSO4 and IB groups. Patients given IB average 32 L greater improvement in peak expiratory flow rate compared with magnesium sulfate (95% confidence interval, 19–43 L) at 180 minutes. Simultaneously, there was a significant reduction in PaCO2 compared with baseline values in IB group but not in MgSO4 group. There was a statistically nonsignificant trend toward a decrease in dyspnea score in both groups although adverse events were similar. Although the improvement in peak expiratory flow rate and arterial blood gas favored nebulized IB over magnesium sulfate, there was a nonsignificant difference between both drugs with regard to hospital admission, intubation, and hospital death rates in patients with COPD treated in the emergency department for acute exacerbation.

Inaccuracy of Thrombolysis in Myocardial Infarction and Global Registry in Acute Coronary Events scores in predicting outcome in ED patients with potential ischemic chest pain

PURPOSE The Thrombolysis in Myocardial Infarction (TIMI) and the Global Registry in Acute Coronary Events (GRACE) scores were largely evaluated and validated in stratifying risk of cardiovascular events in patients with chest pain and acute coronary syndrome. Our objective was to compare these 2 scores in predicting outcome in emergency department (ED) patients with undifferentiated chest pain. MATERIALS AND METHODS This was a prospective cohort study including patients presenting to 4 EDs with chest pain with nondiagnostic or normal ECG. For all included patients (n = 3125), TIMI and GRACE scores were calculated. Follow-up was conducted at 30-day and 1-year post-ED index admission to identify major adverse events. Main outcome included all cause mortality, acute coronary syndrome, and coronary non-ED planned revascularization. Prognostic performance of the scores was assessed by the receiver operating characteristic (ROC) curves. RESULTS We reported 285 (9.1%) major adverse events at 30 days and 436 (13.9%) at 1 year. In patients with low TIMI (≤2) and GRACE (<109) scores, a significant proportion had major adverse events at 30 days (5% and 7.5%, respectively) and 1 year (7.9% and 12.9%, respectively). Area under ROC curve at 30 days was 0.66 (95% confidence interval [CI], 0.62-0.71) vs 0.57 (95% CI, 0.53-0.62), respectively, for TIMI and GRACE scores. At 1 year, the area under ROC was 0.67 (95% CI, 0.62-0.71) and 0.65 (95% CI, 0.60-0.70), respectively, for TIMI and GRACE scores. CONCLUSIONS The TIMI and GRACE scores are not valid in short- and long-term risk stratification in our chest pain patients.

Non-invasive pressure support ventilation and CPAP in cardiogenic pulmonary edema: reply to Templier et al.

Dear Editor, We would like to thank Dr. Templier and colleagues [1] for their interest in our study [2]. They estimate that resolution time in our population is particularly long. Nonetheless, for objective interpretation and to understand the discrepancies observed between our results and those of previous studies it is necessary to take into consideration severity and clinical characteristics of the different patient groups. Indeed, most of our patients did not receive any specific treatment before their inclusion in the study which means that for many of them there is a substantial delay that could adversely influence clinical outcome. In contrast, in 48% of the patients included in the study published by Templier and colleagues [3] drug treatment was started before the introduction of continuous positive airway pressure (CPAP). In addition, compared to patients included in that study, our patients had more comorbidities. It is true that resolution time can be related to the quality of medical treatment. However, this would be unlikely to explain our results as we used a standardized approach in the management of patients with cardiogenic pulmonary edema (CPE) according to current recommendations including those related to oxygen therapy. In our opinion, the main explanation for differences in resolution time between studies is related to the different definitions used. In the study by Moritz and colleagues [4], resolution time was reached and CPAP was discontinued when the patient’s breathing frequency had decreased to less than 25 breaths/min and arterial oxygen saturation (SaO2) exceeded 90% on oxygen set at 6 L/min, or when the same criteria were obtained on fraction of inspired oxygen (FIO2) = 50% under bilevel PAP. In our study, the threshold was more restrictive requiring an arterial oxygen saturation above 96% under lower O2 supplementation (less than 3 L/min and FIO2 less than 35% for the CPAP and non-invasive pressure support ventilation (NIPSV), respectively). We do not agree with the suggestion that the CPAP system should be used with oxygen as the unique gas source whatever the patient’s need. We think that oxygen therapy should be adjusted to provide the lowest amount needed to keep SaO2 above 90% because, over this level, there is no significant benefit regarding the fact that the SaO2– PaO2 relationship is within the flat part of the curve. Moreover, in some patients with obstructive disease history, the risk of inducing acute hypercapnia could not be totally excluded [5]. Therefore, maintaining the arterial oxygen saturation just over 90% is a safer approach than aiming for disproportionately higher oxygen saturations and is unlikely to compromise tissue oxygen delivery. The physiological principles that underlie this advice have been known for almost half a century.