Marcia L. Edmonds

Replacement of Oral Corticosteroids With Inhaled Corticosteroids in the Treatment of Acute Asthma Following Emergency Department Discharge: A Meta-analysis

OBJECTIVES Oral corticosteroids (CS) are standard treatment for patients discharged from the emergency department (ED) after treatment for acute asthma. Several recent, relatively small trials have investigated the replacement of CS with inhaled corticosteroids (ICS), with varied results and conclusions. This systematic review examined the effect of using ICS in place of CS on outcomes in this setting. METHODS Only randomized controlled trials were eligible for inclusion. Studies in which patients were treated for acute asthma in the ED or its equivalent, and on discharge compared ICS therapy to standard CS therapy, were eligible for inclusion. Trials were identified using the Cochrane Airways Review Group register, searching abstracts and bibliographies, and contacting primary authors and pharmaceutical companies. Data were extracted and methodologic quality assessed independently by two reviewers, and missing data were obtained from authors. RESULTS Seven trials, involving a total of 1,204 patients, compared high-dose ICS therapy vs CS therapy after ED discharge. There were no significant differences demonstrated between the treatments for relapse rates (odds ratio, 1.00; 95% confidence interval, 0.66 to 1.52) or in the secondary outcomes of beta-agonist use, symptoms, or adverse events. However, the sample size was not adequate to prove equivalence between the treatments, and severe asthmatics were excluded from these trials. CONCLUSIONS There is some evidence that high-dose ICS therapy alone may be as effective as CS therapy when used in mild asthmatics on ED discharge; however, there is a significant possibility of a type II error in drawing this conclusion.

Randomized controlled trial of intravenous dexamethasone to prevent relapse in acute migraine headache.

Objectives.— Migraine headache is a common presentation in the emergency department (ED). Inflammation is thought to play a role in the pathophysiology of migraine and there is conflicting evidence regarding the effect of corticosteroids on reducing early recurrences. We conducted a randomized clinical trial to test the hypothesis that dexamethasone (DEX) reduced headaches after discharge and examine the factors associated with relapse.

Diagnostic accuracy and clinical utility of emergency department targeted ultrasonography in the evaluation of first-trimester pelvic pain and bleeding: a systematic review.

OBJECTIVE Emergency department targeted ultrasonography (EDTU) offers the possibility of rapid exclusion of ectopic pregnancy in patients with first-trimester pelvic pain or bleeding. We sought to systematically review the evidence describing the diagnostic accuracy and clinical utility of EDTU in the first trimester of pregnancy, and to generate a pooled estimate of the sensitivity and specificity of EDTU for the detection of intrauterine pregnancy (IUP). METHODS The literature search, abstract review and study selection were performed using predefined criteria. We abstracted the sensitivity and specificity of EDTU for IUP from included studies, and evaluated and summarized the evidence assessing the effect of EDTU use on time to diagnosis, time to treatment of ectopic pregnancy, emergency department (ED) length of stay and health care costs. RESULTS The specificity of EDTU for IUP in most studies exceeds 98%. The sensitivity in most studies exceeds 90%. Pooled estimates were not calculated because of statistical heterogeneity between studies. Published evidence indicates that EDTU use reduces the frequency of missed ectopic pregnancies, decreases time to surgery for ectopic pregnancy, shortens the length of stay for patients with normal pregnancies and may be more cost-effective than diagnostic strategies requiring formal ultrasonography. CONCLUSION EDTU is highly specific for the identification of IUP. Patients who have an IUP identified with EDTU may be safely discharged from the ED with outpatient follow-up. The specificity of EDTU for IUP, along with the potential improvements in patient care that EDTU affords, justifies its adoption as routine ED care in evaluating first-trimester pain or bleeding.

Clinical InvestigationsAsthmaReplacement of Oral Corticosteroids With Inhaled Corticosteroids in the Treatment of Acute Asthma Following Emergency Department Discharge: A Meta-analysis

OBJECTIVES Oral corticosteroids (CS) are standard treatment for patients discharged from the emergency department (ED) after treatment for acute asthma. Several recent, relatively small trials have investigated the replacement of CS with inhaled corticosteroids (ICS), with varied results and conclusions. This systematic review examined the effect of using ICS in place of CS on outcomes in this setting. METHODS Only randomized controlled trials were eligible for inclusion. Studies in which patients were treated for acute asthma in the ED or its equivalent, and on discharge compared ICS therapy to standard CS therapy, were eligible for inclusion. Trials were identified using the Cochrane Airways Review Group register, searching abstracts and bibliographies, and contacting primary authors and pharmaceutical companies. Data were extracted and methodologic quality assessed independently by two reviewers, and missing data were obtained from authors. RESULTS Seven trials, involving a total of 1,204 patients, compared high-dose ICS therapy vs CS therapy after ED discharge. There were no significant differences demonstrated between the treatments for relapse rates (odds ratio, 1.00; 95% confidence interval, 0.66 to 1.52) or in the secondary outcomes of beta-agonist use, symptoms, or adverse events. However, the sample size was not adequate to prove equivalence between the treatments, and severe asthmatics were excluded from these trials. CONCLUSIONS There is some evidence that high-dose ICS therapy alone may be as effective as CS therapy when used in mild asthmatics on ED discharge; however, there is a significant possibility of a type II error in drawing this conclusion.

Normal renal sonogram identifies renal colic patients at low risk for urologic intervention: a prospective cohort study

INTRODUCTION Determining which patients with ureterolithiasis are likely to require urologic intervention is a common challenge in the emergency department (ED). The objective was to determine if normal renal sonogram could identify low-risk renal colic patients, who were defined as not requiring urologic intervention within 90 days of their initial ED visit and can be managed conservatively. METHODS This was a prospective cohort study involving adult patients presenting to the EDs of a tertiary care centre with suspected renal colic over a 20-month period. Renal ultrasonography (US) was performed in the diagnostic imaging department by trained ultrasonographers, and the results were categorized into four mutually exclusive groups: normal, suggestive of ureterolithiasis, visualized ureteric stone, or findings unrelated to urolithiasis. Electronic medical records were reviewed to determine if patients received urologic intervention within 90 days of their ED visit. RESULTS Of 610 patients enrolled, 341 (55.9%) had US for suspected renal colic. Of those, 105 (30.8%) were classified as normal; none of these patients underwent urologic intervention within 90 days of their ED visit. Ninety (26.4%) US results were classified as suggestive, and nine (10%) patients received urologic intervention. A total of 139 (40.8%) US results were classified as visualized ureteric stone, and 34 (24.5%) patients had urologic intervention. Seven (2.1%) US results were classified as findings unrelated to urolithiasis, and none of these patients required urologic intervention. The rate of urologic intervention was significantly lower in those with normal US results (p<0.001) than in those with abnormal findings. CONCLUSION A normal renal sonogram predicts a low likelihood for urologic intervention within 90 days for adult ED patients with suspected renal colic.

Familiarity with radiation exposure dose from diagnostic imaging for acute pulmonary embolism and current patterns of practice.

OBJECTIVE To assess the current level of knowledge and practice patterns of emergency physicians regarding radiation exposure from diagnostic imaging modalities for investigating acute pulmonary embolism (PE). METHODS An online survey was sent to adult emergency physicians working at two academic tertiary care adult emergency departments (EDs) to determine imaging choices for investigating PE in various patient populations and to assess their current knowledge of radiation doses and risks. A retrospective chart review was performed for all adult patients who underwent computed tomographic pulmonary angiography (CTPA) and/or ventilation-perfusion (V/Q) scanning in the same EDs. RESULTS The survey response rate was 72.1% (31 of 43 physicians). For patients < 30 years old, 83.9% of physicians chose V/Q scanning as their test of choice, regardless of gender. Although only a third of respondents knew the estimated radiation dose of a V/Q scan (37.5%) and a CTPA (32%), the majority were aware that V/Q scans involved less ionizing radiation than CTPAs. In the retrospective review, 663 charts were reviewed, including 201 CTPAs and 462 V/Q scans. V/Q scanning was the preferred modality in female patients (75.9% v. CTPA 24.1% [OR 2.1; 95% CI 1.5-2.9]) and in patients < 30 years old (87.9% v. CTPA 12.1% [OR 4.8; 95% CI 2.4-9.4]). CONCLUSIONS Although surveyed physicians possessed limited knowledge of radiation doses of CTPA and V/Q scans, they preferentially used the lower radiation V/Q scans in younger patients, particularly females, in both the survey vignettes and in clinical practice. This may reflect efforts to reduce radiation exposures at our institution.

Do Systemic Corticosteroids Improve Outcomes in Chronic Obstructive Pulmonary Disease Exacerbations

Sixteen studies with 1,787 participants comparing corticosteroid with placebo (mostly inpatients) and 4 studies with 298 inpatients comparing parenteral corticosteroid and oral corticosteroid were included. The mean age of study participants was 68 years. The median proportion of men was 82% and the mean forced expiratory volume at 1 second percentage predicted at study onset was 40% (n1⁄4633). Corticosteroid reduced the likelihood of treatment failure by more than 50% compared with placebo (odds ratio [OR] 0.48; 95% confidence interval [CI] 0.35 to 0.67; n1⁄4917). The likelihood of relapse at 1 month was also reduced with corticosteroid treatment (n1⁄4415; hazard ratio 0.78; 95% CI 0.63 to 0.97). However, there was no difference in mortality at 30 days with corticosteroid compared with placebo (n1⁄4 1,319;OR 1.00; 95%CI 0.60 to 1.66).

Are corticosteroids effective in acute exacerbations of chronic obstructive pulmonary disease

E B E M / S Y S T E M A T I C R E V I E W A B S T R A C T S E P T E M B E R 2 0 0 3 4 2 : 3 A N N A L S O F E M E R G E N C Y M E D I C I N E 4 2 7 were sent to the authors for verification. Where author contact was unsuccessful, a second reviewer extracted data. Odds ratios (ORs) and weighted mean differences or standardized mean differences with 95% confidence intervals (CIs) are reported. M A I N R E S U L T S Seven trials that involved more than 600 adult patients were included. Two of the studies were published in abstract form only. Four studies looked specifically at patients admitted to hospital, 2 involved emergency department (ED) patients, and 1 examined outpatients. Outcomes reported varied, and few were common to all studies. The most commonly reported outcome, the forced expiratory volume in one second (FEV1) between 6 and 72 hours after treatment, showed a significant treatment benefit for corticosteroids (weighted mean difference 120 mL [95% CI 5 to 190 mL]). There were also significantly fewer treatment failures in patients treated with corticosteroids; however, the number of trials reporting this outcome was small, and there was significant heterogeneity between them. There was an increased likelihood of an adverse drug reaction with corticosteroid treatment. C O N C L U S I O N S Corticosteroids increase the rate of lung function improvement during the first 72 hours after an exacerbation of chronic obstructive pulmonary disease, but at an increased risk of an adverse drug reaction. There is no evidence that the benefit is maintained after 72 hours, and no clear benefit on other outcomes. comes, including mortality, quality of life, and exercise tolerance. Does this mean emergency physicians should abandon the use of corticosteroids in patients with chronic obstructive pulmonary disease? Perhaps not. Despite the solid techniques used in this meta-analysis, we should be cautious applying these results to our ED patients. The wide variety of patients in this metaanalysis may not be representative of the typical ED patient with chronic obstructive pulmonary disease, and a relatively small number of patients contributed data to each outcome. In addition, the primary outcome of improvement in FEV1 may not measure differences that are important to physicians (who might prefer to decrease ED relapse or mortality) or patients (for whom quality of life might be most important). Of particular note, treatment failure, which combined ED relapse and repeat hospitalization, was a secondary outcome for this study. Despite the fact that there was significant statistical heterogeneity for this outcome, the overall effect showed a marked benefit of corticosteroids (OR for relapse 0.50), and 4 of the 5 studies appear to point toward a benefit of corticosteroids. Subgroup analyses are risky in meta-analyses, but one wonders if certain patients (eg, those with more severe exacerbations) may derive more benefit from corticosteroids. So the debate continues: who, if any, of our patients with chronic obstructive pulmonary disease should receive steroids in the ED? Unfortunately, this meta-analysis does not really answer our question—yet. This systematic review should be due for an update soon (the Cochrane Library aims to have the reviews updated every year2), and Cochrane Systematic Review Author Contact Richard Wood-Baker, DM, FRACP University of Tasmania Hobart, Tasmania, Australia E-mail rhh.respiratoryresearch@dchs.tas.gov.au C O M M E N T A R Y : C L I N I C A L I M P L I C A T I O N S Despite the frequency of chronic obstructive pulmonary disease exacerbations, only a small number of studies have addressed the use of corticosteroids, and significant controversy remains regarding their use in acute chronic obstructive pulmonary disease. Recent studies suggest ED patients are prescribed corticosteroids (65%) more often than antibiotics (30%) at discharge, and clinical practice guidelines often recommend corticosteroids.1 This systematic review searched for the best available evidence regarding the use of systemic corticosteroids in the treatment of chronic obstructive pulmonary disease. The review included studies with patients from a variety of settings (admitted patients, ED patients, and outpatients), with a wide range of severity. The outcomes reported in the studies were diverse, and there was significant heterogeneity between the studies for several outcomes, which limited the amount of data available for pooled analyses. The primary analysis demonstrated a small benefit of corticosteroids in FEV1 at 72 hours, but this benefit was of questionable clinical importance and was offset by an increase in side effects attributed to the medications. There was no demonstrated benefit of corticosteroids on forced vital capacity (FVC) at 72 hours, or on “late” FEV1 or FVC. There were no demonstrated differences for other outE B E M / S Y S T E M A T I C R E V I E W A B S T R A C T 4 2 8 A N N A L S O F E M E R G E N C Y M E D I C I N E 4 2 : 3 S E P T E M B E R 2 0 0 3 research is ongoing in this area. More studies, with standardized outcomes, are needed to clarify the issue. T A K E H O M E M E S S A G E There is insufficient evidence to draw firm conclusions regarding the use of corticosteroids in the acute treatment of chronic obstructive pulmonary disease. Although most current guidelines recommend corticosteroids and their use is common, the evidence is strongest for admitted patients. More studies are needed to clarify the role of corticosteroids in the ED setting, especially for those patients discharged from the ED with an exacerbation of chronic obstructive pulmonary disease. EBEM Commentator Contact Marcia L. Edmonds, MD, MSc Division of Emergency Medicine University of