Mohamed Amine Msolli

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.

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.

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.

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.

Avulsion of the Lesser Trochanter Following a Shot Put Sport Session

Avulsion of the lesser trochanter is an uncommon injury. In children and adolescents it usually occurs as a sports injury via traumatic avulsion of the psoas major tendon. In adults, isolated fractures of the lesser trochanter are most commonly pathological due to metastatic tumor invasion of the proximal femur. This case report documents how a 14-year-old boy, who presented with an avulsion of the lesser trochanter of the proximal femur following a seemingly atraumatic shot put session at a track and field event, was diagnosed and successfully treated with a conservative approach.