M. Silverman

Steroids for Migraine Headaches: A Randomized Double-Blind, Two-Armed, Placebo-Controlled Trial

BACKGROUND Recurrence of migraine headache after treatment in the emergency department (ED) is common. Conflicting evidence exists regarding the utility of steroids in preventing migraine headache recurrence at 24-48 h. OBJECTIVE To determine if steroids decrease the headache recurrence in patients treated for migraine headaches in the ED. METHODS Double-blind placebo-controlled, two-tailed randomized trial. Patients aged >17 years with a moderately severe migraine headache diagnosed by treating Emergency Physician were approached for participation. Enrollees received either dexamethasone (10 mg i.v.) if intravenous access was utilized or prednisone (40 mg by mouth × 2 days) if no intravenous access was obtained. Each medication was matched with an identical-appearing placebo. Patients were contacted 24-72 h after the ED visit to assess headache recurrence. RESULTS A total of 181 patients were enrolled. Eight were lost to follow-up, 6 in the dexamethasone group and 2 in the prednisone arm. Participants had a mean age of 37 years (±10 years), with 86% female. Eighty-six percent met the International Headache Society Criteria for migraine headache. Of the 173 patients with completed follow-up, 20/91 (22%) (95% confidence interval [CI] 13.5-30.5) in the steroid arm and 26/82 (32%) (95% CI 21.9-42.1) in the placebo arm had recurrent headaches (p = 0.21). CONCLUSION We did not find a statistically significant decrease in headache recurrence in patients treated with steroids for migraine headaches.

Prednisone for Emergency Department Low Back Pain: A Randomized Controlled Trial

BACKGROUND Although oral corticosteroids are commonly given to emergency department (ED) patients with musculoskeletal low back pain (LBP), there is little evidence of benefit. OBJECTIVE To determine if a short course of oral corticosteroids benefits LBP ED patients. METHODS DESIGN Randomized, double-blind, placebo-controlled trial. SETTING Suburban New Jersey ED with 80,000 annual visits. PARTICIPANTS 18-55-year-olds with moderately severe musculoskeletal LBP from a bending or twisting injury ≤ 2 days prior to presentation. Exclusion criteria were suspected nonmusculoskeletal etiology, direct trauma, motor deficits, and local occupational medicine program visits. PROTOCOL At ED discharge, patients were randomized to either 50 mg prednisone daily for 5 days or identical-appearing placebo. Patients were contacted after 5 days to assess pain on a 0-3 scale (none, mild, moderate, severe) as well as functional status. RESULTS The prednisone and placebo groups had similar demographics and initial and discharge ED pain scales. Of the 79 patients enrolled, 12 (15%) were lost to follow-up, leaving 32 and 35 patients in the prednisone and placebo arms, respectively. At follow-up, the two arms had similar pain on the 0-3 scale (absolute difference 0.2, 95% confidence interval [CI] -0.2, 0.6) and no statistically significant differences in resuming normal activities, returning to work, or days lost from work. More patients in the prednisone than in the placebo group sought additional medical treatment (40% vs. 18%, respectively, difference 22%, 95% CI 0, 43%). CONCLUSION We detected no benefit from oral corticosteroids in our ED patients with musculoskeletal LBP.

Cutaneous methicillin-resistant Staphylococcus aureus in a suburban community hospital pediatric emergency department.

BACKGROUND Studies on methicillin-resistant Staphylococcus aureus (MRSA) infections have typically focused on pediatric and adult populations at urban tertiary care hospitals. Limited data exist on MRSA rates in skin and soft tissue infections (SSTI) in suburban community hospital pediatric emergency departments (PED). OBJECTIVES To describe the prevalence of MRSA in SSTIs in a contemporary suburban community hospital PED population. METHODS Patients 0-21 years old with SSTI wound cultures who were seen at our PED from 2003-2007 were studied. Data analyzed included type of infection (abscess vs. non-abscess), site of infection, and culture results. Chi-squared and t-tests were used as appropriate; p < 0.05 was considered significant. RESULTS During the study period, 204 cultures were obtained for SSTIs, 11 of which were contaminants. The subjects had a mean age of 12.9 years (SD 6.8 years); 60% were male. The prevalence of MRSA was 27%; MRSA was present in 30% of abscesses vs. 2.2% of non-abscess SSTI (p < 0.005). By year, the prevalence of MRSA was 10% in 2003, 31% in 2004, 33% in 2005, 31% in 2006, and 29% in 2007. No differences between MRSA and non-MRSA infections were present for gender, age, or site of infection. CONCLUSIONS At our suburban community hospital pediatric ED, MRSA was present in 30% of all SSTI wound cultures; MRSA was unlikely with non-abscess SSTI. Our overall MRSA prevalence data among SSTIs are consistent with previously published reports in pediatric ED populations but may be less than those reported in the adult literature.